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Wednesday, November 7, 2007

Chaperones, A Violation of Privacy

Does the use of opposite gender chaperones violate privacy?
A summary of this subject can be found on the companion blog.

201 comments:

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Joel Sherman said...

I have had one concern, largely unaddressed anywhere is the use of medical chaperones. This is often done by disguising the chaperone as an assistant. The patient is rarely given an option to refuse. Chaperones are almost always used when male physicians do intimate exams on women; they are recommended and little controversy occurs. But the chaperones are always women, that is they are same gender and privacy is adequately ensured for most patients. But there is an increasing tendency for women providers to use women chaperones when examining men without giving the patients an option. In my view, when chaperones are used to protect the physician, which is almost always the motivation, they should be presented as such to the patient and an option provided for a same gender chaperone or alternatively for the patient to refuse their presence. The AMA which has guidelines for chaperones does not address this at all, probably knowing that providing male chaperones would be a burden for many offices. But I think that patient privacy rights here should be primary.
The recommendation that chaperones be same gender I have only seen in some UK literature.

Joel Sherman said...

I should add that the way of effecting a solution to the involuntary use of opposite gender chaperones is very different than what is needed for unsanctioned taking of pictures and videos. The latter could be handled by making HIPAA laws clearer on the subject. Given the easy worldwide transmission of digital pictures it only makes sense that the solution be federal. But the feds hopefully have little role in telling physicians offices how to examine their patients. I personally wouldn't want them involved.
Some states do this. Ohio defines not offering a chaperone for all intimate exams as sexual misconduct. Strangely it says little about gender in defining when chaperones are needed. So a male physician doing a prostate exam on a patient could be interpreted as a sex offender if he doesn't offer a chaperone. Changing all state regulations is needed but hardly practical. Here national guidelines are needed and the AMA is the only group that provides them. Writing them is in order. Of course if male patients who object would speak up loudly, the issue would get more attention. Many men do object, but most are silent.

Anonymous said...

Joel,
I have found that almost none of my patients seem to care one way or the other. I recall in my Residency (in the Bronx) finding a Chaperon was impractical. If given the choice to wait for one or get on with an intimate exam, the female patients almost always chose to skip the chaperon. In private practice now, with female patients near to my age or younger than me, I will insist on a chaperon. With older patients, if I know them well, I will frequently give them a choice. Most decide to skip the chaperon.
David

Anonymous said...

Hi Joel. This is Ray Barrow.

My own opinion, for what it is worth, is consistent with the AHA's Patient Bill of Rights. It states, "The patient has the right to every consideration of his privacy. . . Those not directly involved in his care must have the permission of the patient to be present." It is clear from this statement that it is incumbent on the physician to secure the consent of the patient, not vice versa. Given that chaperones are not directly involved in patient care (and, are, in fact, there to protect the physician), then, as far as the AHA is concerned, the presence of a chaperone (whether male or female) violates the patient's right to privacy unless that patient has given consent for the chaperone to be present.

I also agree with the conclusions of appeals courts in two cases -- Backus v Baptist Hospital and EEOC v Mercy Hospital -- The desire of Americans to cover their naked bodies from the view of strangers, especially those of the opposite sex, is a matter of elementary self respect and personal dignity and has its foundation in the fundamental right to privacy. Add to that conclusion the conclusion of the court in Shulman v Group Production -- A man whose right to privacy has been usurped by another "is less of a man, has less human dignity, on that account. He who may intrude upon another at will is the master of the other and, in fact, intrusion is a primary weapon of the tyrant." Thus, it would appear that the courts in Backus and EEOC would consider the use of male chaperones with female patients and female chaperones with male patients without their consent especially egregious privacy intrusions (espeically if intimate procedures are involved) and the court in Shulman would consider the physician as using the "weapon of the tyrant" in order to serve his/her own interest at the expense of the patient's dignity.

If physicians violate patients' dignity by using chaperones without patient consent, then, by so doing, they also violate the very first principle of the American Medical Association's "Principles of Medical Ethics" -- "A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity" -- and should be reported to the State Board of Healing Arts for doing so. Similarly, if a nurse, whose role includes patient advocacy, chaperones a physician without patient consent (therby deviating from her/his role), s/he also violates her/his first code of nursing ethics -- "The nurse provides services with respect for human dignity and the uniqueness of the client. . ." -- and should be reported to the State Board of Nursing. Indeed, those who do not report this behavior, whether patients or healthcare providers, tacitly encourage it and, thereby, do a disservice to their fellow Americans. -- Ray

Joel Sherman said...

David, I agree with you. Most patients are comfortable without a chaperone especially if it is a long term patient. But I assume you are only referring to using women chaperones for female patients. The situation is quite different when a woman physician uses a female chaperone for a male patient, usually without asking permission or even passing off the chaperone as an assistant who may do nothing more than hand the doctor a pair of gloves. That's what I think is a violation of privacy. The choice should always be the patient's, not the physician’s when there is no medical reason for an extra person to be in the room. Needless to say a physician can always refuse to do the exam if she feels there is a real problem with the patient.

Ray, great post. More to follow.

Anonymous said...

David, I assume when you write that your patients don't seem to care one way or another, you are referring to the presence of a chaperone who is the opposite sex from the patient. If you are interested, I cite numerous studies regarding patient preference for sex of provider and write about the motives for their preference on Dr. Maurice Bernstein's blog regarding patient modesty (Saturday, October 20, 2007 10:27:00pm and Monday, October 22, 2007 6:48pm).

I am curious as to your reasoning for treating older patients and those around your age or younger differently. Will you tell me what it is?

If you continue to obtain consent from older patients but not from younger patients and those around your age, I assume that as you age, all other things being equal, you will be obtaining consent from fewer and fewer patients. Can I infer this from what you have written? -- Ray

Anonymous said...

I don't really think this would be an issue if the man was there to see a female physician already. One would assume if he's comfortable with a female doctor, he wouldn't mind the female chaperone. I still think it should be up to the patient who's included in the exam, if this is not respected he should see a different doctor. JMO

Jimmy

Joel Sherman said...

Jimmy, there are no available statistics as to what percentage of men would object. The point is that they are rarely asked, and they should be asked whenever an observer comes in. The AMA says that in a different context, but doesn't apply it if the observer is a chaperone.
But I disagree that a man who sees a woman physician wouldn't mind anyone else being there. I would have no difficulties seeing a woman physician, she’s a professional, but I would not like being exposed to the office unnecessarily. The AMA recommends that a chaperone be a professional, but they could be anyone. Most practices can't afford to pay nurses’ salaries to have them stand around and watch all day. So they would use whoever is available, probably an aide, but it could even be a secretary.

Anonymous said...

You all have introduced an interesting empirical question -- interesting to me, anyway. After reading posts by a number of people including a nudist who expressd discomfort at his body being scrutinized by two clothed females, one whose presence was unnecessary, I suspect you're correct, Joel. However, it might prove very difficult to find a sample of men who have had such an experience in order to answer the question. -- Ray

Anonymous said...

Joel,

Sorry Joel, I misunderstood.

What I meant to say was that if the chaperone was a professional (as in a nurse), that the individuel probably wouldn't mind. I do agree with you that the use of aides and especially the secretary shouldn't be allowed unless otherwise granted by the patient. I guess what's most disturbing to me would be that the physician thinks so little of his patients that he pulls anyone from his office for this type exam. At any rate, the doctor should state who this assistant is and ask the patient to proceed. Nobodys at fault then.

Jimmy

Anonymous said...

Jimmy -- Regarding use of secretaries, etc. to "assist" physicians, there is an interesting 1881 Michigan case John H. De May and Alfred B. Scattergood v. Alvira Roberts. The case reads as follows: "a physician took an unprofessional friend with him to attend a case of confinement [a woman was delivering] when there was no emergency requiring the latter's presence. The physician told the patient's husband that he had brought a friend with himn to help him carry his things, and he was accordingly admitted [to the couple's home]. The patient, on afterwards discovering the facts, sued both in damages. Held, that the plaintiff and her husband had a right to presume that the outsider was a medical associate; that in obtaining admission without disclosing his true character, the defendants were guilty of deceit; that plaintiff had a right to testify that she had supposed he was a physician or medical student, and also to give evidence of whatever may have been said at the time tending to support such supposition. . . In obtaining admission at such a time and under such circumstances without fully disclosing his true character, both parties were guilty of deceit, and the wrong thus done entitles the injured party to recover the damages afterwards sustained, from shame and mortification upon discovering the true character of the defendants." -- Ray

Joel Sherman said...

Here are 2 paragraphs from UK literature which gives preferences of patients about the use of chaperones. Note how they say that many men, especially teenagers don't want female nurses present. So far I can't find any such recognition in the US literature:

"What considerations should direct the use of chaperones? Several studies have sought patient preferences in primary and secondary healthcare settings,3–7 although not in genitourinary medicine. The findings show remarkable consistency. Male and female patients differ markedly in their desire for a chaperone. Most women want the offer of a chaperone and feel uncomfortable asking for one if it is not offered. Most teenagers want a chaperone during intimate examinations, and a family member may be the preferred choice. Many women prefer having a third party present when the examining doctor is male, fewer if the examining doctor is female. For women a female nurse is generally the preferred choice as chaperone, would be accepted as a routine part of the clinical examination, and is generally viewed as having a positive supporting role during the examination. Men, however, particularly teenagers, find the presence of a female nurse as observer during genital examination unwelcome. Interestingly, a substantial proportion of patients in primary care didn’t mind if a chaperone was present or not,7 although this finding may reflect an older patient sample and familiar doctors.

These findings suggest some strong imperatives. Every woman having a genital or rectal examination should be offered a chaperone. Failure to offer one deprives patients of support they may want, and non-availability is an unacceptable excuse. It is unacceptable for a teenage woman to be alone with an unfamiliar male physician for genital examination. Moreover, it shouldn’t be assumed that a female nurse will be an acceptable chaperone for a man."

Could it be that British medicine cares more about the patient and American medicine cares more about the physician?

Anonymous said...

Joel,

Your Q:Could it be that British medicine cares more about the patient and American medicine cares more about the physician?

Maybe the British doctors are respected more and don't have to worry about getting sued as much? American medicine has to protect it's doctors because of this. With everything that is wrong in medicine, I also think they get hit with to many frivolous lawsuits. Are there as many lawsuits in Britain than here on average?

JK

Anonymous said...

JK -- It would seem to me that if U.S. physicians took the British study to heart and acted on it, the result would be an increased likelihood of trust between patient and physician, an increase in rapport, and a reduced likelihood of law suits if the physician made a mistake which harmed the patient. There is considerable evidence that the greater the rapport between physician and patient, the less likelihood that a lawsuit will follow mistakes made by the physician. I'm home right now and don't have access to the sources off the top of my head, but can dig them up tomorrow for anyone who is interested.

A quick aside -- Several years ago, a colleague of mine commented on the many frivolous suits against hospitals/doctors (His wife was a physician). I'm ashamed to say that rather than expressing skepticism, I acknowledged the validity of his assertion. Well, since then, I've studied the matter and, in retrospect, should have asked him to name one case so I could look it up, study it, and make up my own mind (as I did that with the McDonald's coffee spill case). So, now that's what I do -- even to the former Missouri Speaker of the House. The cases may be out there, but nobody I've asked so far has been able to name one yet. Can you? -- Ray

Joel Sherman said...

JK, yes American physicians are at much greater liability risk than the British, but it does not explain this disparity.
A male physician uses a chaperone with a woman to increase the patient's comfort and to protect himself against liability. The chaperone is always the same gender as the patient. Reverse gender would be considered inappropriate in this country.
But the reverse situation plays by opposite rules. When women use a chaperone examining men, the chaperone is nearly always opposite gender, i.e. another woman. Is this needed for liability concerns? Suits against women for sexual impropriety during exams are exceedingly rare. I have only heard mention of one such case and been able to find no references. Instead of increasing the patients comfort, it usually increases discomfort. The use of chaperones should be voluntary in this situation and the patient given the option to refuse by asking beforehand. There is sufficient evidence that most men would turn it down.

Ray, there are lots of frivolous lawsuits against doctors. Most don't make it to trial and you don't hear about them. The throw away journals carry a lot that did make it to trial, e.g. the doctor who couldn't get a case dismissed against him though he never saw the patient who was actually seen by his long deceased father.

Anonymous said...

Joel and Ray,

I need to clarify my statement once again. I merely answered based on what is normal in todays society. Unfortunately, these law suits are there not just for doctors to deal with, but many other professionals. I don't want to get into a debate about which ones were frivolous or not.

How would this issue not affect how a doctor practices? If it was me, it would weigh heavily on my mind and because of this I don't feel that the doctor and patient can ever build any kind of trust. I do agree that it all boils down to trust and we need to work on those things that can build the patient-doctor relationship back up.

JK

Joel Sherman said...

Finally I found an American position paper that backs my position, i.e. that chaperones should be voluntary. It even mentions opposite gender as a separate issue. I believe it is from a malpractice carrier.
I did express my opinion to the AMA a week ago, and have just received the promise of a response.

Joel Sherman said...

The issue has been raised as to how common chaperone usage is. Hard to get solid data in the USA. Nearly all male physicians use chaperones for intimate exams on women and by that I mean pelvic exams. The usage for breast exams is almost certainly much less. I have never seen figures for women physicians doing intimate exams on males in this country. In the UK, one study I saw gave the figure as 10%. I have the impression that the percentage here is highly variable with some clinics mandating them and others using them only infrequently when there are special concerns. Training may also differ from school to school. My strong sense is though that the frequency is increasing as legal concerns in this country continue to escalate. If anyone has any data, please post it.
Remember that there are really two issues here, the privacy of patient information which means that a patient should not have to relate their medical history in front of observers, especially if they are not licensed professionals. This aspect the AMA does consider in their recommendations. The other aspect is modesty, especially with opposite gender chaperones. The AMA does not consider this worth mentioning.

Joel Sherman said...

An interesting reference on voy documented that 89% of men did not want or were 'indifferent to' chaperones being present for examinations by the opposite gender provider. The analogous percentage for women was 45%. Only 11% of men wanted them for this. When the examiner was the same sex, only 3% of men and 11% of women wanted chaperones present. The complete reference can be found here.

It does not surprise me that only a small number of men want chaperones in this situation. It's surprising how few patients really want chaperones at all. It just adds further proof to the fact that in this country the overwhelming reason for them is for protection of the doctor and that they should always be voluntary when opposite gender chaperones are used.

Anonymous said...

Upon reading the article I could not help but notice the issue of the gender of the chaperone was barely addressed. I would suggest that if it were, there would have been additional points of contention. It was noted that the assoc. of ob/gyn suggested female chaperones. While I don't think most men want a chaperone in most cases, I would bet the issue of two females (doctor and female chaperone) would meet more resistance. Likewise if the 55% of females who answered yes to wanting a chaperone with a male doctor were told the chaperone would be male, I am guessing the percentage would drop significantly. Yet that is what is forced on most men when a chaperone is utilized by the Dr., many times they just don't know it JD

Anonymous said...

Dr. Sherman wrote: "It just adds further proof to the fact that in this country the overwhelming reason for them is for protection of the doctor..."

In disciplining a physician in 1996 the New York Administrative Review Board for Professional Medical Conduct wrote:

"The board has expressed our reservations in the past, however, over trusting a patient’s safety to a third party monitor who is a paid employee of a Respondent and whose continued employment depends on that Respondent remaining in practice. The Board concluded that if we could never trust this physician around patients or their mothers without a third party monitor, that this physician was unfit to practice medicine in New York."

Yet for some reason, medical boards all over the country (including New York) continue to use mandatory chaperones to "protect" patients from predatory physicians.

CLW

Anonymous said...

CLW, This is my main problem with a chaperone provided by the doctor themself. Just how many of these paid by the doctor champrones would report their employer and loose their livelyhood? A few but not many.

MDC

Joel Sherman said...

MDC, chaperones being in cahoots with the physician is a theoretical problem, but I doubt that it is a real one. I have looked at some of Mike's 800+ cases. Not a single one has implicated this as being part of the problem. Maybe Mike can comment about all of them. If it happens, it must be very rare.
Hard to know what else practically a physician could do to protect patients. It would hardly be feasible to contract for chaperones from an independent source though perhaps it could be mandated for physicians who have already been accused of misconduct.

Joel Sherman said...

Just another quote from a UK article that chaperones should be voluntary:

"If the patient is offered and does not want a chaperone it is important to record in the Patient Medication Record (PMR) or similar that the offer was made and declined. If a chaperone is refused a healthcare professional cannot usually insist that one is present."

I still have trouble understanding why only the British seem to recognize a patient's primary right to privacy in these situations. The AMA never did respond to my email.

Joel Sherman said...

An interesting article which concerns the use of chaperones quoting from the medical board of California:

Many of the dropped complaints involve a misunderstanding of the law, said medical board spokeswoman Candis Cohen. A female patient will file a complaint against a male doctor because he didn't have a chaperone present, though there's no legal requirement to do so.

Patients sometimes complain about what they think is inappropriate touching but is a necessary part of a medical exam. Or they'll say a doctor leered.

"What can we do with that? We can't substantiate a leering allegation," Cohen said, asserting the board pursues any case that can be substantiated.


The use of chaperones is not mandatory in any state that I know of, though some states such as Ohio, may make the offering of chaperones mandatory.

Anonymous said...

Thanks for the reference, Joel. The article makes it clear that all the complaints were by female patients against male physicians and punitive action followed 16% of these complaints.

Taken as is, the article reinforces my belief regarding how important it is for the physician to communicate with the patient and vice versa. It also reinforces my belief that it behooves the physician to shoulder the major burden to find out what the patient's needs and expectations are, not only because he occupies the more powerful position, but also to protect himself. -- Ray

js said...

we just switched dermatologists because we did not like the fact that a young female accompanied the doctor in the room during a full body check. Supposedly, the purpose of this was for the doctor to dictate their findings and the assistant put it on a small computer. Even though we were not completely disrobed for a man to be in their jockeys was uncomfortable. The derm doc we saw in another state for years never did this. When we stated we did not want anyone else in the room on our visits, we were looked at as ODD. Is our society so unbothered with body exposure? These girls that work in offices are nothing. They may have recently quit a job at a fast food restaurant.

Joel Sherman said...

JS,
This dermatologist is not the only one to use an assistant to take notes. If you have lots of lesions that need to be followed it is perhaps reasonable. But I wouldn't care for it either. It is a significant loss of privacy.
You made your feelings known and changed physicians. That's all you can do. If you're not the only one, the doctor will get the message eventually.

Joel Sherman said...

The proceedings of the state medical board on New Jersey changing the regulations so that it is mandated that chaperones be offered to pediatric patients undergoing breast or genital exams. The clear understanding is that the offer can be refused.
As is almost always the case in this country, the regulations appear to be written gender neutral, i.e. a woman provider must offer a chaperone to a female for a pelvic exam and a male provider must do the same for a rectal exam on a male. I can't understand why they can't have different rules for same and opposite gender encounters, as the need is dramatically lessened for same gender encounters, though clearly it is not zero.

Anonymous said...

Joel -- I understood the decision of the N.J. Board of Medical Examiners a bit differently than you. I don't think it was limited to pediatric patients. Gartland expressed her concern in the first "Comment" that minors would not be covered, but the Board's response suggested they would. Most of the other exchanges and the rules as stated seemed to apply to patients in general.

I also don't believe the Board "mandated that chaperones be offered to . . . patients undergoing breast or genital exams." It mandated that physicians "provide notice" of patients' "right" to have a chaperone in writing, a conspicuous posting, or some other way. If a patient doesn't ask for a chaperone, the physician doesn't have to offer him/her one. More specifically, "patients should be notified of the option to have a chaperone present [only] when the patient believes that it is necessary. . . In addition, during these specific examinations, physicians are only required to have chaperones present when the patient has requested one." So, it appears that patients need not say anything if they don't want a chaperone present.

On the other hand, if the physician wants a chaperone present and the patient does not, then the physician can refuse to provide care to the patient (13.35-6.23, 2(d)) and is obligated to inform the patient of the consequences of not truckling to the physician's preference. In this case, the physician does not offer the patient a chaperone but makes his/her services contingent on the presence of a chaperone. Everything written to 2(d) is clearly meant to protect the patient's interests. 2(d) is clearly added to protect the physician's interests.

Regarding your argument, the logic behind it seems to go something like this -- different rules should be used to protect people from misconduct depending on the frequency of the misconduct. Homosexual misconduct between physicians and patients occurs less frequently than heterosexual misconduct. Therefore, there should be different rules governing homosexual and heterosexual misconduct between physicians and patients.

How might the Board respond? Well, its members might agree and ask what the different rules should be. Or they might argue that since male physicians are more likely to engage in sexual misconduct with female patients than female physicians are with male patients, should there be different rules for these two scenarios as well? But, they might be more likely to respond to your argument as they did to one of Dr. Diehl's arguments. Although he personalized his argument, it was, in effect, that misconduct between physicians and patients don't happen frequently enough to warrant any rule to protect patients. The Board disagreed claiming that there were enough complaints to warrant the rules. They might respond to you in the same way -- there were enough complaints to warrant equal protection to patients from both heterosexual and homosexual misconduct by physicians. -- Ray

Joel Sherman said...

I think you're right Ray that the regulation is intended to apply to all medical offices. I did say that only offering the chaperone is mandatory, but a posted offer does seem sufficient. Clearly patients can refuse. The regulation is not clear that a patient must be given the option to refuse though.
I was trying to contrast this with the Ohio regulations talked about on Bernstein’s dormant thread 'naked' where it is defined as sexual misconduct not to offer a chaperone doing a genital or rectal exam. As gender is not mentioned it is clearly possible for a male physician to be classified as a sex offender for merely doing a rectal/prostate exam without offering the patient a chaperone. (Posted notices are not referred to in the Ohio regulation.) That scenario is what I think is absurd. Generations of doctors have done same gender rectal exams without ever even thinking of a chaperone with no problems. That's why I think that you get into absurdities if you don't differentiate between same and opposite gender care. The risk of a sexual assault or accusation with same gender care is small enough that it makes no sense to require chaperones. It would make as much sense to require a chaperone every time a nurse or aide exposes a patient as well.

Anonymous said...

Joel: I agree, the Ohio regulation seems to go way overboard.

Regarding informing patients about their chaperone option in N.J., I've been trying to imagine how the posted notice might read. Were I an independent physician, I think I'd post it with a patient's bill of right modeled after the AHA's "Patients' Bill of Rights" and add to it, "Patients have a right to have a chaperone present during examinations." Probably nobody would read it. (When I've gone to the clinic here, I've asked other patients in the waiting room if they have read the patient's bill of rights posted on the wall. So far, everyone has said "no.")

If the notice read, "Female patients have a right to have a chaperone present during examinations," I probably wouldn't get any readers either.

I can imagine that strange things might happen were one to post either notice and patients read it. The first might titilate the imagination and a request for the promised chaperone of a male exhibitionist. The second might provoke anger by a radical feminist.

What I like best about the N.J. decision was that it added, "some patients may provide their own chaperones for their examinations." Although the wording makes it appear that this option is not mandated, its inclusion is a step toward the creation of policies by healthcare providers to allow patients to bring their own chaperones (or advocates) unless medically inadvisable. I submit that were we to question a probability sample of Americans, they would tend to believe that such a policy is an important indicator of "respect for patient." I also submit, that were this option offered to and utilized by patients, much of the callous treatment we read about on Berstein's, allnurses, and patientdoctor blogs would not occur. -- Ray

Anonymous said...

I would like to call the attention of this blog's readers and posters to the following url:

http://www.drlaw.com/MEDICAL-NWSLTR-Medical-Chaperones.pdf

"The Medical Newsletter" found
here demands chaperones for doctors without the slightest concern for patients. It implys that this dictate should not be made known to patients in advance but that they should be refused service if they do not agree to whatever level of humiliation the doctor finds necessary for his possible legal defense. Real in your face medical arrogance.
-- CHUCK McP

Joel Sherman said...

Thanks for that reference Chuck. Please note that it comes from a law firm that specializes in medicine and is much stronger than the AMA's recommendation for example. If you ask for legal advice, that's what you get, a lawyer's view on how to maximally protect yourself, not how to practice medicine. If I took that advice, I wouldn't even shake hands with a patient without a chaperone in the room.
In my 40 years of practice I have rarely used chaperones (I don't do genital exams). No woman has ever complained when I listen to their chest and heart. If one did, I would certainly bring in a chaperone, but honestly if the patient trusts me that little I would rather they go elsewhere. Other doctors have different policies. But I try to practice medicine, not law.

Joel Sherman said...

Here's an article about special considerations for the examination of children by medical students with a close look at the need for chaperones. As always it seems, this comes from the British literature who again are the only ones who seem to look at this issue from all sides.
I never gave it any thought before, but certainly medical students are close enough in age to older adolescents that it is a special situation even apart from their lack of experience.

Joel Sherman said...

A review of the subject as it applies to female pelvic exams from the Obstetrics and Gynecology journal. The article makes it clear that the use of chaperones for pelvic exams is not universal in the US (to my surprise) and in fact many women would prefer not to have them. The article also makes clear that there is no consensus in this country as to their use for any exams, but instead a confusing mix of state recommendations and individual custom.
This topic is a long way from settled.

Joel Sherman said...

Here's a nice summary article about the use of chaperones. As usual, it's from the UK.
They seem to be the only ones who look at the use of chaperones from all view points and not just the medicolegal. Note that they leave open the question of chaperones for male patients, acknowledging that many men are not comfortable with female chaperones present.

Joel Sherman said...

An interesting twist here. A male nurse in England sued over requirements that he have a chaperone present when doing ECG's on women in contrast to female nurses who had no such requirement when they worked on men. He won on appeal to the National Health Service, but ultimately quit the nursing field. He's not the only male nurse to suffer discrimination.
I know this same problem can arise in some American hospitals though I'm aware of no suit based on it. To my mind the need for a chaperone should be determined by the patient's wishes and not by hospital fiat.
I'll also post this under the Equal Employment thread.

Joel Sherman said...

Here's another screed from a lawyer saying why physicians should use chaperones all the time. The only reason given of course is to protect the doctor. Not a thought is given to the actual risk involved which is clearly dependent on the type of encounter. They don't give a passing concern to patient privacy either, although they do say same gender chaperones should be used if requested. But that is not the only privacy issue.
As I said above, I don't base my medical practices on lawyers.

Joel Sherman said...

A few people have expressed doubt or surprise that non medical people can be used as chaperones. For those who doubt here is an online UK ad for a receptionist whose duties include being a chaperone.
Although there is nothing legally wrong with this as chaperones do nothing but watch, most people wouldn't feel any better having the receptionist watch their physical exam. At the very least, they should be a trained medical assistant.

Joel Sherman said...

Here's kind of an unusual case from California, a doctor had his licensed suspended for not using a proper chaperone for a child's exam, though he states the parents were present. This doctor had been in prior trouble or there would have been no chaperone requirement, but I can't see what's wrong with using parents as a chaperone for a physical exam (as opposed to a history if there is a question of abuse). Who can be trusted to protect kids if not their parents?

Anonymous said...

My family moved and my dad insurance changed because of his new job. My mom took me to the doctor for a physical before school started, when they called my name back I was taken to a general area where they take every ones vitals and then I was shown back to a my exam room and told everything off and put the gown on. When the doctor came in my mother was with her she must of asked her to follow her back. We were told that group of doctors requires a chaperone for people under 18 yrs. old and that my mother would have to stay for yr whole physical because they were short staffed that day. I have never seen a female doctor before my mother told me later she just assumed it was a male when she made the apt..
My gown came off for the hernia check and the inspection of my rear and I found extremely embarrassing when the doctor told me to bend over the table and spread my cheeks for her to take a look. I have never been naked in front of a female before besides my mom and she has not seen me naked since I was 12 yrs. old. I am not trying to be a baby but this all happened so fast all because the doctors office was short staffed. I would have much more liked a stranger to chaperone then my mom because at that age you are trying to have privacy around the house and respects others privacy. The doctor never said they were sorry for the inconvenience it was all very matter of fact and also happened so fast. To go to the doctor for a physical that the school required and to be giving a complete physical in front of a strange female doctor and my mom when I was fully developed was very embarrassing. I never returned to that female doctor except for a cold because then I turned eighteen and yes today I do have a female doctor but she is much nicer then that doctor and no chaperone. I never wanted to move in the first place and I did not speak to my mother for three days but it was not really her fault and I would not have faulted the doctor if she tried to make the best of the situation IE.- not being being so matter of fact, asking me if I was okay with this, maybe turning the chair the other way or asking my mom to look the other way for five minutes. Or maybe we would like to reschedule since they where overbooked and understaffed.

Andy

Joel Sherman said...

Andy,
To be clear, no state requires chaperones to be present and no insurance companies do either unless there has been a prior problem or accusation. As you say, this was an office policy only. If you have read through the above you will see that males overwhelming prefer that chaperones not be used and adolescent males are even more uncomfortable with it. Despite this, many practices (and some parents) are not sensitive to the issue where boys are concerned. This is an attitude that dates back to a prior era and is only slowly changing.
Pediatrics remains a special case and there are no rules as kids mature at different ages. Mothers are usually present for their children’s exams, but the age when this should stop is dependent on no fixed rules. But 17 is far too old. A physician should be asking personal questions about sexual problems by that age, and it can't be easily done in front of parents. Any pediatrician (and parent) should be sensitive to these problems and ask the child what their preference is. Usually it would be obvious if the child is embarrassed. Routine genital/hernia exams are not so critical that they can't be postponed, especially if you've had regular check ups.
With girls the issues are somewhat different. Male pediatricians would generally not do a genital exam without a chaperone present, and many girls (not all) prefer their mother be present for their first full pelvic exam.
In short, there are no hard and fast rules, but it is incumbent upon pediatricians to be sensitive to the feelings of adolescents, and many are not, especially for boys. Few kids are able to voice active protests in these situations, but going elsewhere is the best you may be able to do.

Joel Sherman said...

Here's an article by a female pediatrician out of Boston discussing the use of chaperones in multiple situations. She clearly recognizes that boys can be embarrassed by it, but she doesn't say how she deals with it. Does she skip the chaperone or pay no attention?
Traditionally, men have been made to feel that it's their fault if they're embarrassed; they need to 'get over it'. Of course women are treated differently. I'm not clear how this pediatrician deals with it. Be interesting if she said more. Hopefully times are changing, but not rapidly.

Joel Sherman said...

Here's a good sensitive summary about the use of chaperones during genital examinations, both for men and women, adults and teenagers.
Of course it is from the UK again. American medicine has trouble looking beyond the legal issues to actually consider patient preferences.

Joel Sherman said...

A recent American study on chaperones from Vanderbilt states that only half of female patients want chaperones when a male does a pelvic exam on them and only a quarter want it when a female does the exam. For men, 88% 'did not care' about the use of chaperones during genital exams. The abstract didn't break that down into how many men would go further and not want a chaperone present.
The study points out that chaperones are used far more often than patients desire them.

Anonymous said...

The conclusion is the only thing
of importance here because they
left out all the important details
from the survey as reported.

What were the genders of the
chaperones present for males and
females? Does "men did not care"
mean they could "care less about the presence of a chaperone one way or the other" or they "didn't need one to be present to be comfortable with their doctor"(?) These summaries always amaze me as those who write them appear to have no understanding of what the survey was trying to determine. At least, the overall conclusion, that doctors use more chaperones than patients desire is a positive evaluation for the patient-side of this issue.
(Amir)

Joel Sherman said...

I will try and get the original article, Amir. My guess is that it won't say too much more as it is apparently only a few pages long. I'm sure the British articles cited above are better, but there's so few American articles that I'd like to see it.

Joel Sherman said...

I have finally read the above article from Southern Medical Journal Volume 101, Number 1, January 2008, p 24-28.
The study has several significant limitations, some of which they recognize. It was conducted in an ER setting, but no clinical data about the patient's complaints are included. The acuity of the illness obviously makes a difference. Thus if I was in pain and acutely ill, I'd be a lot less concerned about chaperones than when I went for a routine checkup. The demographics of the patients are also not given and there are certainly population differences. The article states that 2% of men wanted chaperones when examined by women and 11% did not. (Perhaps not unexpectedly, 3% of men wanted chaperones when the examiner was a male!) All the rest didn't care. Based on the British articles above, I find that unlikely. But the article then states that all patients preferred same gender chaperones, women more so than men, but no percentages are given.
So the article leaves many questions, but the major flaw is the dynamics of the physician patient relationship are vastly different in an ER setting with sick patients and personnel who are strangers than in your own doctor's office for routine visits. Their major conclusion though seems valid, that is far less people care about chaperones than physicians are led to believe from the literature.

Joel Sherman said...

Here's a summary of another British study on patients’ wishes concerning chaperones. It agrees with what I've posted above, that many patients don't want chaperones at all. A new statistic, both men and women overwhelmingly preferred to be asked if they wanted chaperones to be present. Women tend to accept them when the examiner is male, but in the reverse situation, males prefer not to have them.
It's time American medicine and the AMA recognized patients’ wishes in this regard.

Anonymous said...

In researching physician sexual misconduct, I have read quite a number of state medical board discipline reports where a doctor who is being put on probation (!) for sexual misconduct will be required to have a chaperone as a condition of his probation. The sex of the chaperone is not specified. I wonder how many women would be happy with a male doctor and a male chaperone? How about female doctor with male chaperone for female patients? How about female doctor and female chaperone for male patients?

CLW

Joel Sherman said...

Your right, the sex of the chaperone is never specified in disciplinary actions, but since 99% of chaperones are female, I think it can be assumed. No statistics as to the sex of chaperones is available.
I have never heard of male chaperones being used routinely in the US no matter what sex the patient is, though I have seen it alluded to in the UK.
Have no idea what percentage of women would accept male chaperones. There would be sufficient complaints that no physician would consider it, plus the legal protection to the doctor would be less which is almost always the point of using chaperones.

Anonymous said...

This is hard to understand. If a woman would accept the professionalism of the male doctor during an intimate exam, then why not also accept the professionalism of a male nurse? Are male nurses inherently less able to control their sexual impulses than male doctors?

CLW

Joel Sherman said...

CLW, I have read about the use of male obstetric nurses. Although not the norm, they certainly exist. When fully supported by the institution, they are accepted by most patients. For some, it may take a little getting used to, but that's all. But male obstetricians are very unlikely to use male nurses as chaperones. Although many patients would accept them if they trusted their doctor (and most do), the doctor would get less legal protection and be more subject to complaints. As protection of the doctor is the major reason for chaperones, they have no incentive for using them.

Joel Sherman said...

Here's a long interesting story about a gastroenterologist sued by a patient for sodomy during a colonoscopy. This was done in his private office, in a curtained off area, but apparently no nurse was in immediate attendance though one could have walked in anytime. It illustrates why male physicians need chaperones.
The doctor was convicted and lost everything, but the verdict was overturned on appeal and a new trial held. The doctor was offered probation if he pleaded guilty the second time, but he refused. He was found innocent on the second trial.
The case points out what a great disadvantage men can be in sexual assault trials if the judge refuses to admit into evidence the relevant past history of the plaintiff. The attorney in ultimate charge of the case was Linda Fairstein, the head of the Manhattan sex crime division for many years, but now a well known author. She has stated that about 10% of the sexual assault claims that came through her office were phony.

Joel Sherman said...

Here are three letters from the British Medical Journal commenting about chaperones in follow up I believe to one of the articles I've previously quoted. Two of the 3 writers pretty much agree with my position that the use of chaperones needs to be tailored to patient's wishes as well as the doctor's perceived needs. One believes that chaperones are always a must for legal protection. The letters are generally referring to female exams and don't consider male exams where the dynamics and risks are totally different. The bottom line should always be that the patient's wishes be given priority except under unusual circumstances.

Joel Sherman said...

Here's a post off voy's medical forum, definitely not a source of reliable information. It's often considered a fetish board and has many abusive posts. But what follows is one of the more believable posts:

Well yes I am present in the room to assist the doctor during all exams. This is simply as a defense for the doctor against any possible false accusations by a patient. Yes it is my personal observation that this seems to distress the younger male patients more than the older ones. It is very common to see flushing of the face, incoherence of directions, and the infamous nervous erection begin to show through the gown upon realization that two females will be conducting the exam. If older males do feel this same distress then they are a lot better at hiding it than the younger ones.
Now as far as the physician I work for, she is very kind and I feel is sensitive to the issue of the double standard. The reason I feel that she complies somewhat to it however is because in our society females for whatever reason do expect a higher level of modesty and are quicker to balk and take up the torch whenever they feel that modesty has been violated. She is however extremely sensitive, especially to males patients, during these procedures by giving them verbal reassurance, etc. Usually the male patients other than being embarrassed have little in the way of complaints about this, there have been a few who have asked if I could please leave when they have to show their penis, but we simply explain that I'm there to assist and we know it's embarrassing but it will be over before they know it and this seems to sit well with them. That being said I feel that she is a very competent and sensitive physician who complies to the double standard simply to avoid any ugly issues which might arise from trying to enforce a completely level playing field. I feel this is the issue with the medical community as a whole as well, taking a female hypersensitive to perceived violation and put her in a lawsuit happy country and it can spell trouble.


She tries to make the policy sound reasonable, but it's not IMO. There are some exams which are intrinsically embarrassing and just can't be helped. I have no problem with that. But this is not one of those instances. The presence of an extra person witnessing an exam where the man is clearly embarrassed cannot be justified for any reason, let alone a medical one. Women physicians are at such low risk of being sued for sexual impropriety that it is outrageous to claim that they need a chaperone for legal protection. And the double standard is immense. They wouldn't dream of bringing in a man to chaperone a female patient.

Anonymous said...

Yes, Dr. Joel. Truly outrageous
reasoning for a regularly
scheduled appointment. I
make it a point to never go
to women doctors. If I ever
have to have one, I will go
in with gun drawn and both
barrels cocked. These men
are being ambushed. You have
to be ready for this when it happens. Thanks to blogs like yours and Maurice Bernstein's,
I am ready. But I don't let
these moments develop if I can
avoid them. I first voice
concerns about privacy when I
make appointments. I always say,
"I want to be examined by the
doctor in private." If he/she shows up with a chaperone, I'll repeat myself. If he/she can't accommodate me, then I'll walk and remind the desk that this factor was a condition of my seeking care there. Don't bill for it or we'll have trouble. NO MORE MEDICAL AMBUSHES FOR ME. I'M RIDING SHOTGUN, all the time.
Enough of this double-standard BS.
-- Kyle

Joel Sherman said...

Thanks Kyle. I'm glad someone finds these blogs educational.

Anonymous said...

In reference to the Aug 6 post, it seems to me that the doctor is subjecting herself to greater potential for an impropriety accusation. A complaint can be made against 2 females as easily as one. The whole idea of a chaperone is to reduce appearances of impropriety and to give comfort to the patient by having someone of the same sex present. That's why a male doctor won't consider, I would suspect, having a male chaperone with a female patient. If this doctor feels she needs to have an assistant, then she should hire a male for those times she has a male patient. The cost of her peace of mind, shaky as it is, shouldn't be at the expense of the patient's dignity. Personally, I would terminate such an exam on the spot and walk out. I will simply not allow 2 females to do any kind of personal care or exam.

I wish the assistant had posted if she turns away for the more embarrassing parts of the exam. I suspect she doesn't.

It's great to read these posts and see that I am not alone with my apprehensions about female caregivers. I have have too many bad experiences.

Mike

Joel Sherman said...

Mike, I personally don't think that it would make a significant difference as far as the doctor's legal defense what the sex of the chaperone was. It would usually make a difference to the patient though.
Again the basic question is does a woman physician need any legal protection? Her risk is so minuscule of being accused of sexual impropriety that I don't think any violation of the patient's privacy can be justified, unlike the situation for a male physician and female patient.

Anonymous said...

Dr Joel,
I suppose if the day ever comes when a female doctor is accused of impropriety with a male patient, then we will know if the sex of the chaperone makes a difference. Legally speaking that is. I agree that the female physician does not need the chaperone, given the fact that men are unlikely to falsely accuse. It's sad to know that this doctor is willing to subject her patients to unnecessary distress for a non-existant fear.

The subject of men having their modesty violated because of some unrealistic fear of the part of female healthcare providers is something I have experience before. I guess it was about 1997 when I went to a urologist for a prostate ultrasound as part of an infertility workup. A female medical assistant came into the room and left the door open, I mean ALL the way open, not just cracked. She announced her plan to expose me to position me for the procedure, and I literally had to push her hands away to get her to stop trying to pull the drape off of me. All I had on was my shirt and a paper drape around me. I told her that before we would do anything she would have to shut the door. She said it was office policy that the female assistants had to leave the door open when in the room alone with a male patient. I told her that was unacceptable and to trade out with a male assitant, which is what I had on a prior visit. She said the male assistant was not available. I told her that I would have to leave. Then she went and got the male assistant and we did the procedure. I complained of course and I was assured that changes would be "considered". I never went back to that uro so I don't know if that ever happened.

How many men have suffered in silence?

Mike

Joel Sherman said...

Mike, I applaud your response to a horrendous violation of your privacy. It's hard to imagine any office having a policy of deliberately exposing patients to anyone in the hall. I might have pursued it further by filing a complaint with the state. I certainly would have been ruder. And no provider better ever tell me that they're bringing in a chaperone or exposing me for 'my protection.' My response to that lie would be to ask whether they would assault you if no chaperone was present.
I can't really support your contention that men are less likely to falsely accuse though. I've just seen no statistics on that. Most 'false' accusations are misunderstandings of what the medical procedure was about rather than outright lies. There have been rare accusations of sexual misconduct against women physicians. Probably no chaperone was present. I certainly wouldn't know if the accusations were true.

Anonymous said...

Dr. Joel,
I suppose somewhere there are statistics as to accusations made against physicians, but not being in the field I don't know how to access them. Perhaps the AMA has info. I can say that men are less likely to file complaints based upon my own experiences. I am personally guilty of allowing some inappropriate behavior to go unpunished for many reasons. They include: not knowing who to go to, shame and embarrassment, just preferring to let it go rather than getting stressed over it, and procrastination. If you have read much of what is on allnurses, I am 58flyer. Some of my experiences are posted there.

You can bet I raised some serious hell over the incident with the urologist. I filed complaints with every agency I could think of. That's where I got my revelation about the role of medical assisants and the realities of their supervision by physicians. I got their attention, but no real action was taken. I may have just harrassed them into making change. A very good personal friend of mine is a urologist there. I avoided seeing him because of our friendship. He did assure me changes would be made. I did not press him on the subject due to our friendship. It was not the only time I had a problem with that particular clinic, but it was the last.

Mike

Joel Sherman said...

Mike, I am sure women lodge more complaints than men on these subjects, but I suspect their veracity is similar to men’s.
I think you did very well with your complaints. I wouldn't have expected any formal sanctions to be handed down for complaints like this unless they were repeated and ignored. But that doesn't mean that you didn't accomplish a lot. It doesn't take many complaints to change behavior. It's not as if the practice is making money off disrespecting your privacy. They know they are losing patients when you complain and it is in their interest to correct it. I'd be interested in knowing why they instituted this policy. My guess is that it's not because they think you might complain about something. More likely some patient harassed the technician and they're doing it to protect her. If so that means they don't trust their patients which would be sufficient reason for me to go elsewhere. They have lots of more appropriate ways of keeping the infrequent obnoxious patient under control.

Anonymous said...

Dr. Joel,
I'm not sure about the stupid policy either and your speculation that it had something to do with a past experience with a disagreeable patient is probably correct. Personally, I don't think there was any such policy. I think the MA just made it up as a cover for her laziness, but since she lied about the status of the male assistant's availability, she probably lied about that too. Maybe she was just personally uncomfortable being alone with an undressed male, and maybe the office allowed her to make that call. As you pointed out, the practice can't make any money if patients are dissatisfied and go elsewhere. Maybe they allowed her to do this unless patients complained, which I certainly did, but she still didn't shut the door. If she was uncomfortable with male patients, perhaps a urology clinic was not the best fit for her. They certainly lost my business, and since I never let an opportunity slip to tell people about my experiences with them, I'm sure I cost them some business.

My first experience with this clinic some years earlier went bad thanks to a bad doctor. He was later arrested by undercover police officers while engaged in immoral activity with gays in the city park. That earned him a reputation around the town and within the medical community. It was later revealed that he secretly videotaped exams and procedures of his patients, male, female, young and old. Quite a story, but I am not sure how appropriate it would be to put on this blog. Am I allowed to mention the name of the clinic?

Mike

Joel Sherman said...

Mike, it's incredible that a urology clinic would have a gay sexual predator on its staff. Sure to make a large number of potential patients stay away.
I don't have a strict policy for using names. Obviously if you are quoting public stories (especially if you give news links) it’s fine, and we have many of those on this blog. I would delete unsupported personal rants. For anything in between, I would use my judgment as to how much supporting evidence and details are given.

Anonymous said...

Dr. Joel,
I have googled myself stupid trying to find something in the public domain about the urologist. I think it may be too old by now. I can only report what I personally know based on my experiences. I saw this guy the first time in 1983 for a lump on a testicle. I held off for a whole year trying to get the courage up to have it checked. I was terrorized by the thought of female involvement after the horrific experience I had as an adolescent. I wrote of that on the allnurses forum. Anyway, I finally got some encouragement from, of all people, a girlfriend who was a nurse at my job at the county jail. I doc seemed a little weird, but otherwise nice. My girlfriend stayed in his office and read while I went to the exam room. I was given a large gown that wrapped 1.5 times around me, so it covered very well. The doc does the exam uncovering more and more as he goes. Then it's time to stand up for the hernia check and I went to pull the gown back around me but the doc said just leave it on the exam table, using words like "it's just us guys here." I still didn't like it but I went along. I kept noticing that as he examined me he stayed to one side or the other with a mirror on the wall directly in front of me. Like I really wanted to watch myself get examined in a mirror. He had me turn around and bend over the table stark naked for the DRE. I kept worrying if someone would walk in. He got done, handed me a tissue container for cleanup, and headed for the door. Before I could say or do anything, he had that door wide open and walked out. I stood there shocked like a deer in the headlights totally naked and of course there has to be a female medical assistant just outside the door. Thank God she was looking the other way. I cleaned up and got my clothes on, and then wondered about the mirror. It did occur to me that it could be a 2 way mirror but I brushed that off. There was a door to the right of the mirror and I tried it but it was locked. I tried to move the mirror but it was mounted solid against the wall. The doc said he thought I had a torsed appendix of the testicle and proposed surgery. I told I would get back with him. After we got back in the car I told my girlfriend about the experience and she was hot. I mentioned the mirror and she blew that off saying there was no way that would happen due to civil liability. But at least I was happy it wasn't cancer.

A few years go by and I made it out of the jail and got assigned to patrol with the sheriff's department. A couple of friends of mine were working a morals detail undercover and arrested the doc for weeney wacking in the park with the queers. I think it confirmed what a lot of people suspected about him all along, that he was a perv. It made the papers and embarrassed the clinic. He agreed to get couseling for his deviancy. I don't recall if there was some action by the medical board or not, but his practice kept him on since he agreed to counseling. More years go by without anything else occurring until about 1997. He gets arrested for internet porn involving kids. Police serve warrants at his house and at the clinic. All this occurs during my battles with another doc at the same clinic, mentioned earlier. So all this stuff is going on at the same time. The news reports it but, strangely enough, not in a big way. The items found and collected as evidence included hi8 videos, downloaded porn, and magazines.

At that time I was flying in the aviation unit and while on a call I got a message from dispatch to report to the police station to meet with a sex crimes detective. I wasn't too concerned about that because my previous assignment was as an evidence technician and I was always getting called in to discuss prosecution matters in high profile cases. So I landed my helicopter on the roof of the police station and went inside and met the detective, who was someone I knew well. He said he had something for me to see. I went to an interview room and he plugged in a hi8 cartridge into a player and turned it on. There I was in living color naked as a jaybird getting examined, I couldn't bear to watch the DRE part, too detailed. The tape runs while I clean myself up and get dressed. You can even see when the doc opened the door and the medical assistant was standing outside. I was ready to kill him. I wasn't alone. This guy had videotaped people getting exams for years and some prominent people and members of my police department were caught on film. A lot of kids were filmed too.

The doc agreed to surrender his license and practice no more. The clinic was done with him of course. A lot of people caught on film never knew it as the tapes were destroyed. It would have been tremendously embarrassing for it to go to trial and have all that introduced as evidence. Since the doc gave up his license the prosecution didn't hit him too hard. I don't think he pulled too much time but he got some hefty fines. Once all was done he moved out of state.

Sorry this has moved off the topic of chaperones.

Mike

Joel Sherman said...

Thanks Mike,
I don't think the name of the ex doctor (I hope) is important. But if the case had made the papers and with all those details I would have permitted it. Certainly it at least gives full credence to any one who doubts the story.
Is it your story I referenced from allnurses under privacy violations?
Feel free to also post this story under that heading or under videos.

Anonymous said...

If the poster you mention on allnurses is 58flyer, then yes, that is me.

Mike

Joel Sherman said...

Here's a summary of a UK study (it's always from the UK) re patient preferences for chaperones. It has a few new tidbits as well as confirming what's above. 15% of patients prefer chaperones and 15% never want them. The rest prefer to be asked each time. New info for me is that 74% said that office staff as opposed to nursing staff were unacceptable as chaperones, hardly a surprise. As usual there were differences between male and female patients with more of the latter preferring chaperones, but still in the minority.

Joel Sherman said...

Here's a very serious and generally sympathethetic article about cancer screening for men which recognizes male issues with modesty and embarrassment. It's written by 3 women.

Yet they say this:
Should a clinician choose to screen for testicular cancer using a clinical testicular exam, communication about the exam before performing it can reduce anxiety and embarrassment and provide an opportunity to normalize conversation about sexual problems, sexual organs, and other sensitive topics. Establishing a trusting relationship with a younger male patient before any exam is crucial. Adolescent patients can be preoccupied with body image and are prone to embarrassment and shame in the medical encounter. If the patient is uncomfortable, the provider should consider having a chaperone in the room.

Amazing that these women could have so little understanding of adolescent male modesty and embarrassment that they would recommend having a chaperone, 99% of whom would be women, in the room to help(!) the patient.

Anonymous said...

We need to have an official definition of what a chaperone is. In the care of women by men, it is generally understood that a chaperone would be of the same sex as the patient. That needs to carry over into the care of men by women. From the article it is hard to tell if that's what the authors are referring to. One would think that if the male patient is uncomfortable with the exam being performed by a female clinician, how are things going to suddenly improve with the presence of another woman in the room? Obviously that would make things worse. Sad that such simple logic is lost on what most people would assume are very intelligent people.

Mike

Anonymous said...

I also find it disturbing that a chaperone would be of the opposite sex. That one would be just grabed from the office is uncomprehensible..
What most fail to recognise is that many of us are not all that fond of being naked in front of anyone else...even a male doctor.
To ask for an "audience" to witness an already embarrassing situation is to heap it on...and to do it with a member of the opposite sex just to make the doctor think it resovles the issue when it only makes it worse is ridiculous.
I recently had to have an ultrasound of testes.. I requested a male tech, but was informed there was not one on staff and ws offered the chance to have a chaperone..they were taken back a bit when I said I did not want an audience...they would only have had another female anyway.
leemacaz

Anonymous said...

I read an article about five yrs. ago it was about female doctors in a male doctors world. I had found it on Google and do not really remember how I came across it.

It was a bunch of surveys and polls from female doctors and some interviews. I was taken back a bit with some of the answers when it came to the female doctors with male patients (use of chaperons).

Many of the female doctors use chaperons because the doctor is uncomfortable with the male patient in different stages of undressed and even though the male patient gave them no reason to feel that way. Some of the doctors stated if a second pair of eyes was present it would keep the patient in line.
Another reason was the female doctors reputation in the outside world. It basically said was the doctors did not want male patients going out of the office and telling there buddies they got a hand job from this doctor or something like that. It also said some of the doctors knew how embarrassing this was for some male patients but it kept everything on the up and up for them.
The female doctors also said this goes for many male doctors that the use of a chaperons speeds up the office visit and turns patient quicker, that if a patient is feeling awkward with the presents of a second pair of eyes that they are less likely to ask questions during the exam.
I found this article seaching for something in the modesty depatment for a expierence I had and I am sorry I do not have a link. Itr really makes you wonder about what doctors both male and female think of there patients?

Seth.

Joel Sherman said...

Seth, too bad you can't find that link. It confirms what I've said above several times, that chaperones are used to protect the physician, not the patient, 99% of the time. Male physicians have no practical choice in the US when doing a pelvic exam (but it's not considered mandatory in the UK). But women physicians are never under such constraints as their risk is miniscule. When a woman physician uses a chaperone for a man, she is saying that she is uncomfortable and/or doesn't trust the patient. I'd go elsewhere.
The cancer article doesn't specify gender Mike, but since male chaperones are a rarity in this country they'd have to if that's what they meant. And I agree that most men don't want any chaperone, but a woman is more embarrassing for the majority of men. Does anyone think that the 3 women who wrote that well meaning article would if they had a daughter of their own who was embarrassed, recommend that a man be brought in to watch? It's ludicrous. That 3 presumed experts on the subject of male embarrassment could make such a recommendation is mind boggling to me. These are women who care, yet any boy forced to be expose himself before multiple women is a candidate for never coming back. Or even worse, he may develop a fetish and decide he likes it, coming back for the wrong reasons.

Catherine said...

Hi Joel --

I am the lead author of that article you quote, and thank you for considering it sympathetic, as it was certainly meant to be. As I mentioned in an email to you, I completely agree with your take on that one statement from our article -- we SHOULD have said male chaperone – or family member, or someone who the patient would feel supported and comforted by. However, as you rightfully note, there are few male chaperones available and this not be an option in many practices. When that article was written, there were few physicians even considering the issue for male patients, so I am glad that we helped to raise some awareness. You did catch us on this unfortunate misstatement, and I do appreciate it. But isn't it nice to have women who feel passionately about promoting men's health? We like men…

Seriously, we do seem to have a problem in this country with how men are treated in the healthcare system -- and this is one part of a larger picture. For years, there were “women’s health supplements” for existing NIH grants, but I never saw a “men’s health supplement.” More work needs to be done, and men need to champion the idea.

Further, to answer your question -- no I would not want my daughter (or myself) to be put in a situation where there were 2 men watching a sensitive exam -- but it has happened -- usually with trainees.

The chaperone issue is a big one that needs to be sorted out, and patient-centered models can help. A chaperone should be a patient advocate, and should be a comfort to the patient, not just one more person peering under your skirt (speaking from personal experience). I believe that there is a serious deficiency in training both clinicians and chaperones that needs to be addressed. Where do chaperones stand? What do they do? I would suggest that they stand out of the sightline of the exam, and focus on helping the patient cope with feelings, sensations, pain or discomfort -- and perhaps facilitate communication between clinician and patient. There needs to be research showing how chaperones can be effectively used to enhance patient comfort and the physician-patient relationship, and decent guidelines need to be developed. We need solutions that strengthen the therapeutic relationship, not the opposite.

Thanks for bringing this issue up. If anyone would like to collaborate on research about these issues, please let me know. Perhaps there is some funding out there.

Keep up the good work.

Anonymous said...

And the doctors who just grab someone as a chaperone..(witness) to cover their butts think they are building a trusting relationship where the patient will have faith in their medical ability??? Credibity is so hard to achieve yet so easy to destroy.. If you lie about one thing..How do I know what is the truth...
There goes the doctor/patient relationship...not just for that one doctor in the eyes of the patient...but all doctors will probably get tarred with their error in teh future..much harder to get the goodwill of a patient then.
leemacaz

Anonymous said...

Before all the training of the chaperone lets see if the patients even wants one. Some doctors just pull someone from the front desk. Gee I always love paying my bill to the person who just witness me get a hernia check and a DRE.

MOST MEN DO NOT WANT A CHAPARONE. WE OUR JUST SLIGHTLY TRYING TO RECOVER FROM BEING A TEENAGER AND OUR MOTHERS WATCHING OUR EXAMS!!!!

Anonymous said...

Catherine
I have to tell you I am really encouraged that you and Dr.s like Dr. Sherman and Bernstein have taken up this issue. I think we...I...tend to adopt a male against female attitude about this. To have three female researchers acknowledge and support the issue is very encouraging. I for one avoided medical care after a bad experience. It wasn't until I read blogs like this one that I started requesting accomodation that made me comfortable. It is a long way from where we need to be, but a step. Thanks to all of you providers who are doing something to help reduce the number of men dying from embarressment...it happens more than we are willing to admit, I know several of my friends who have suffered the consequences of avoiding care when they needed it because they were to manly to ask for accomodation and to embarressed to seek help...alan

Anonymous said...

Dr. Sherman,
I am starting to wonder if there really is a shortage of male personnel for doctors offices. Years ago I went to a private technical school pretending to be a prospective student to see for myself just what a medical assistant had in the way of training. I wasn't impressed but this one school did have a placement program for helping graduating students find jobs. That's as far as I went with it but it would be interesting to see if male medical assistants really have trouble getting jobs. The urologist I went to last year of course had no male assistants and I asked him about it. He said that he leaves his hiring decisions up to his office manager, so the doc never sees any applications from anyone, let alone males. His office manager, a female, had no medical background. So it left me to wonder if there really is a shortage of men willing to work in doctors offices. The doc did say that a male assistant could only work with male patients, an obviously discriminating position to take, but even so with men making up a significant portion of a urologist's practice that still shouldn't be a problem. The point I'm trying to make here is that there might not be a shortage of men to work as assistants in doctors offices, just an unwillingness to hire them.

I certainly agree with your statement about a female doctor using a female chaperone for HER own comfort. She might not be as comfortable if her assistant is a male.

Mike

Anonymous said...

Catherine,
Allow me to join Alan in thanking you for taking an active role in male modesty concerns. Your continued work in this area may well save lives in the years to come.
Alan,
I could have written your last post myself in that I too had a horrifically bad experience as a patient with a female nurse. (I'll post that experience on this blog when I get the chance) Following that experience I lived with a painful lump on the testicle for over a year before getting it checked, fortunately is wasn't cancer but had it been I wouldn't be here today. How many men have had embarrassing and humiliating experiences and then shied away from care because of it, only to die from abstaining from care that could have saved them? We will never know.

Mike

Anonymous said...

Just go on Craigslist or another job search website and you can see first hand how little these so called professionals that will be witnessing many intimate procedure need none to little experience. "But we are all professional here"

Catherine said...

Thanks to all who appreciate the research work and our collective mission in the area of patient-centeredness and men’s health. There are many kindred physicians who share the patient-centered or relationship-centered view. To find one, check out the American Academy on Communication in Healthcare http://www.aachonline.org. Its membership includes physicians and others who are truly committed to patient respect and learning/teaching strategies for partnering with patients for improved health. One guiding principal of such partnership is to ask for patient preference and approval for most anything that occurs in the medical encounter. Ask before touching – ask before bringing up a sensitive topic – ask before bringing a third party into the room, etc. This promotes patient autonomy, but also enhances partnership between clinician and patient – and a working partnership is critical to effective medical care. If a man (or a woman) does or does not want a chaperone of either gender, or a family member or other support person, present, that is THEIR CALL, and they have the right to be included in this decision and to accept or refuse. If a third party is necessary for a procedure, for example, then a negotiation between clinician and patient should follow, and a mutually agreeable solution found. Paternalistic (or maternalistic) clinicians who make these decisions without consideration for the patient and without including the patient in decision-making (unless the patient is unconscious or unable to make a decision, and has no family to assist with decision-making) – well these clinicians are simply not practicing good medicine. It is indeed unfortunate that such problems with some clinicians endure. The lasting damage of even one humiliating experience with a single clinician can indeed have persistent negative effects that can effect both health and quality of life. There are good clinicians out there – don’t give up until you find one.

Anonymous said...

MENS HEALTHCARE IS NOT A SPECTACTOR SPORT but it sure seems like it.
Grade through high school I had school/sports physicals most of the time it was with a female doctors and they checked for a hernia and every time the female nurse was two feet away. She was there to assist the doctor but how do you assist the doctor with a hernia check, you do not so you just end up starring at the boy lowering his shorts.
When we went to a regular pediatrician for a physical our mother had to stay in the exam room for our physicals (doctors rule). That was always very awkward as I was getting to become a young man because my mom stopped seeing me without clothes since I was eleven.

In the hospital when I was eighteen years old I was diagnosed with Non Hodgkins Lymphoma within the first week of a major operation I had six enemas all given by female nurses, I was prepped for surgery the night before my operation by a female nurse. On the night of my operation I could not urinate so they told me a Foley would have to be inserted, not one nurse but two nurses were there to inserted it. I was in so much pain from the operation but for about six minutes the embarrassment of two female nurses only maybe five years older then me inserting a Foley and being freshly shaved I really wanted to die.
Now doctors want to use chaperons during intimate exams to make them feel more comfortable, when is it my turn turn to feel comfortable in a medical setting because I yet to feel that feeling.

Seth.

Anonymous said...

So that lady wants us to buy a membership? I do not think so!!!

Seth- your right on it about males being exposed to just more then the doctor during an exam and largely the opposite sex, from a early age. thanks for sharing.

Anonymous said...

A chaperone should ALWAYS be same sex as the patient. ALWAYS. It defeats the purpose if they aren't as part of the reason they are supposed to be there is patient comfort. The other part is legal protection for the doctor but patient comfort should always come first.

I'm sure it isn't easy getting male nurses for doctor's offices but it would then be best to ask the patient if they would prefer the exam alone or have them bring a chaperone for their own comfort.

I don't believe male or female doctors should be forced to provide an exam without a chaperone but if the patient doesn't want one that should be taken into account as well. If more patients would get up and leave doctors would then get the hint.

I never have a chaperone nor does my wife. My relatives grew up in a time where there was no nurse in the room and still prefer it that way. While many women like a chaperone a lot of other women don't. This problem isn't one that only men face.

For the record, neither my wife nor I have had a problem with having our requests granted here.

I'm surprised we haven't seen more lawsuits like the one mentioned above with people suing for non-medical personnel being a chaperone and/or assisting. That's a huge invasion of prvacy.

CM

MER said...

I just left a comment on Dr. Bernstein's blog about this. Basically I asked why the AMA doesn't establish some real standards regarding chaperones. Is it that they just don't think it's an issue or are they afraid that basic ethical standards regarding chaperones (especially with men) are disregarded so often that they'd be too many complaints?

I so glad to see Catherine Dube commenting on this blog. I've given copies of her article about Talking with Male Patients, etc. to many medical professionals. Most are really surprised at reading about stereotypes regarding men's modesty. Most have never thought of it as an issue. But they take it more seriously now, I think.

Shortly I'll post some standards coming out of the UK regarding these kinds of issues. Because they have a National healthcare system they're required to have National standards and patients get more input into those standards. Not that they don't have their own problems within their system. They do. But there's a conscious attempt to deal with male modesty issues and I'll give you some striking examples that I challenge anyone to show me being done in this country.

Anonymous said...

Once again I want to thank all of those involved in this. I don't think Catherine was attempting to sell a subscription, she was trying to give resources. I also copied the article and sent it to several local providers. While I don't think sending a single article will change anything, I think it is a start and a piece of the puzzle. I know for a fact men avoid or delay medical attention due to the issue of modesty and lack of options. When I turned 50 my PCP started nagging and nagging me to get a colonoscopy. I went in where the woman signed me in and discussed the insurance issues with the colonoscopy, a female lead me back and told me to get undressed and put on the gown, a different female nurse entered and discussed the procedure, a female anesteiologist came in and gave her talk, two female nurse/techs came and got me and wheeled the bed into the exam room, so there I was in the room with three females (2 techs) and the anesth. My Dr. comes in..finally a male like me...they turn on the IV to put me out, but start the procedure (and exposure) before I am out, when I wake up there is a female recovery nurse, who gets another female recovery nurse to wheel me back to my curtained room, we exit the exam room where 4-5 female nurses are standing around talking and I am wheeled through them, one of them makes a funny remark...have fun?....how could she have the nerve...becasue it is a small community hospital and I know most of the partcipants including her...my point, the intimidation fact that many males feel in a predominately female setting is very very underapprecated and not truely understood, there are reasons males do not utilize medical care....I truely believe this is one of the main ones. And while we can pass it off as the gender disparity in nurses/techs available the question then becomes...what is being done to address it, the answer...little to nothing. We recognized the need for more female Dr.'s and the benefit for female patients...but completely ignore it for nurses and males....that, it the problem. If people who are in Ms. Dube's position shine the light on it enough....it might empower us to also address it and we might see change...thanks again Catherine, I for one really appreciate it. alan

Anonymous said...

I am sorry Catherine is trying to sell subscriptions. Remember in health care it is all about the almighty dollar. Her intention may be good but it is still like a fund raising campaign. If you want a caring health care environment I have the answer and I am going to make you pay for it.

Alex

MER said...

I want to point out an article in the March 16, 2006 issue of Nursing Standard, publication out of Great Britain. The article is titled "Male Urinary Catheterisation" by Willie Doherty who is a clinical nurse specialist.

After discussing what the process is and why one does it, Doherty has a section called "The Role of the Female Nurse." In the past, he says, only males did this procedure on males. But the result was that males had to often wait too long in pain to get the job done, so female nurses were taught the procedure. Doherty discusses the intimacy of the procedure as says now males can have the procedure done without having to wait. But, he writes: "However, patients should always be give the choice of the gender of the nurse or doctor performing this intervention, as with any other clinical situation or intimate procedure. The patient's wishes should be foremost in the decision making process and he may not wish a female nurse to undertake this procedure."

He does say to offer the male patient a chaperone of the same gender, and specific to our current discussion about chaperones, he writes: "The Royal College of Nursing (2002) and the General Medical Council (1998,
2001) have published guidelines on chaperoning and intimate examinations and the nurse should be aware of local policy on chaperoning." These British policies indicate that patients should always be offered a chaperone of the same gender.

Now, I'm pointing out this article because I don't think you'll find this kind of policy coming out of American medical magazines. If I'm wrong, someone please correct me by showing me examples.

What's even more interesting, I think, Doherty has a section in this article about male sexuality in which he writes: "Male sexuality is an important consideration for female nurses undertaking male catheterisation.
Milligan (1999) stated: ‘the penis is considered by many to be the focus of male sexuality. Compared with female sexuality, male sexuality is more concerned with power and performance and more physical (Lawler 1991). This has an
impact on the practitioner and the male patient as the penis is being manipulated (Fader 1986).

How much of this kind of psychology/sociology is even covered in doctor/nurse training? If it is covered, it seems to be set aside or forgotten soon after the doctor/nurse gets into the healthcare "system."

I have some other articles coming out of Britain on these issues that I'll point out later.

Anonymous said...

I greatly appreciate all who post here and especially teh ones who can site papers or sites or organisations concerning this issue.
The ladies who wrote the article on chaperones and their rethinking the wording about chaperones for males was very encouraging and are to be thanked.
As to a chaperone for me:
1. If I need one with a male doctor...I do not want the doctor.
2.I do not want a female clinician or technician to begin with and a chaperone would be of no use to me. (Nothing to do with feeling inappropriateness on the Doc's part either.) Just how I feel (embarrassement period)and NO I am not being gender discriminatory...I am sure the females are as competent as the males.
3. I do not want an audience..Period.
4. If they do not trust me or I do not trust them, I nor they, need each other.
leemac

Joel Sherman said...

Shortly I'll post some standards coming out of the UK regarding these kinds of issues.

Please do MER, and include a link if available. If you've read thru this thread, you will see that nearly all the studies on chaperones come from the UK.
As I have said repeatedly, they seem to focus on real patient privacy whereas we focus on physician protection. There is more need for the latter in this country, but the patient's needs should always come first.
I think it would be unusual to be able to get a man to catheterize a male patient on most shifts. Most male nurses tend to work in the ICU and ER and just aren't available for routine floor work.
Thanks for all the posts. Just not enough time to comment on all individually.

Anonymous said...

First, merely by having another person present there is a violation of the privacy between patient and doctor..no matter what credentials the other party may have.
Second, although I think I can understand Alexs feelings about paying for anything, I do not share them because A.The folks doing the studies have expenses and have to live. B. They are sure less expensive and in better position to make needed changes than expensive lawyers..and without all the hard feelings.
I, for one, am glad and pay when I can to support this cause. Not being ridiculed or embarrassed is worth a lot more to me than I can pay for as it is..
Catherine has only privided an access to sources not otherwise available.
I am jsut gratefull for any and all help we get.. it beats having to endure all the cliches and humiliations.
Again I can understand Alexs reluctance to want to pay... I hope he understands why I am not.
leemac

Anonymous said...

There are tons of chaperon statements and guidelines from many places around the world. I have noticed many of UK guidelines. I have also seen many hear in the USA from regular hospitals, teaching hospitals, for private doctors and yes even the lawyers.
GOOGLED IT.

Anonymous said...

Lee- You do whatever you need to do to get you through your day, medical exam and life.

Stay Strong
Alex.

Anonymous said...

When faced with a "forced" chaperone ...doesn't that in essence violate the confidentiality
that medical folk are supposed to maintain? And irrespective of whether they are an assistant or a receptionist couldn't you claim that right to confidentiality as abasis for a refusal? I only mean the assisstant because it appears many are used for no other reason than as a chaperone... I am sure if one was truly needed the doctor could explain why.
leemac

Anonymous said...

What also bothers me about the doctors office lately is the paperwork, far to much personal information that they do not need to treat us as patients. Everyone says are information is private and it may be but look at the turnover in offices lately. Hundreds of local want-ads a day for health care workers and the ads are asking for less and less experience. I am hate to break it to the industry me being chaperoned in the office is over and if it was not over the chaperons or assistant would need a lot more experience as a health care worker. I would also would have to recognize the person of being a long standing employee of the office.
This day and age of that office wanting me to fill out all of this outrageous paperwork and having just any employee stand there when I am getting a hernia check is over.
Seth.

Catherine said...

Alan -- You are right, and thank you for your kind comments.

Alex - You couldn't be more wrong. Believe it or not, there are still people in this world who try to help others without compensation.

This is important work, and thanks to everyone posting here for their insights and comments. I am learning a lot from these posts, and I do appreciate the moving stories and sincere concerns that are being shared here.

Catherine said...

MER --

Strangely, the male genito-urinary exam was NOT TAUGHT in many medical schools until recently. The medical school I am currently affiliated with is adding it into their curriculum this year -- and my previous medical school added it to the curriculum as a result of our lobbying efforts related to the study of communication skills for men's cancer screening we were conducting. Other issues, such as modestly and chaperones are catch-as-catch can -- but oddly, the exam itself was missing from teaching at many schools -- let alone how to do it right (both from a technical and psychosocial perspective). The licensing board for medical schools (LCME) has a standard that all medical schools have to meet: "ED-22: Medical students must learn to recognize and appropriately address gender and cultural biases in themselves and others, and in the process of health care delivery." Although quite broad, it can be used as leverage to improve teaching in this area.

Joel Sherman said...

Catherine, I agree that male genital exams were not traditionally emphasized in medical schools. I cannot remember having specific instruction in them. It was an era where female pelvic exams were mandated on admission to a hospital at least in some states whether specifically needed or not, but male exams were not an issue.
Seth, the paper work is imposed on physicians by payers, insurance companies, etc. No physician wants to impose it unnecessarily.
Leemac, I think an involuntary chaperone violates all kinds of things, but the medical establishment (read AMA) doesn't recognize it as a violation.

Anonymous said...

It is ridiculous to have an office worker stand in for the protection of a physician (male or female). what do they think people are? Pieces of meat with no feelings. Get back to basics. I announced at the front desk (quietly) that I did not want an audience while I had a skin check and I was laughed at. Evidently, front desk office staff find this amusing. Maybe they should sit at the front desk and greet people in their underwear?? What the hell is the difference? People need to speak up and if needed walk out. Things would change in a hurry.

Anonymous said...

Ray, your statement about the nurses creed and treating each patient individually with respect..yada, yada, yada. Well guess what-- you can properly file a formal complaint with the board of nursing and you know what? Nothing, I say nothing is done. NADA... That is all "good" sounding dialogue for the books. It is not enforced one ioda. It would be laughed at and tossed in the circular file.

Joel Sherman said...

you can properly file a formal complaint with the board of nursing and you know what? Nothing, I say nothing is done.

Not sure which post you're referring to, but nursing boards frequently don't have a lot of disciplinary power or it may be combined with other state agencies. I would start complaints with the hospital which should always respond to you.

Anonymous said...

It was the Nov 8, 2007 post referring the the "oath" of a nurse.

Anonymous said...

Here is an interesting article on Patient Modesty, Communication and Chaperons.

Seth...

http://www.financialpost.com/related/links/story.html?id=798125

Joel Sherman said...

Thanks for that link Seth. It is a rare one that mentions the use of same sex chaperones. But it still doesn't explore the idea fully.

Anonymous said...

Yes, not much said on chaperons but I was basically referencing the whole article. I know anyone could write a book but Dr. S. what is your opinion on the article, if you care to share. Dr. B says time and time that is not how he teaches his medical students. My take is more leaning towards the article because doctors themselves could change many things in there surrounding. So I am guessing many med students are taught very different.
Seth.....

Joel Sherman said...

Seth, I had no reservations about the article which I'd commend. But teaching these skills is not an easy thing to do. I think most physicians learn more by experience than by formal lectures. That's what residency training is about. Unfortunately, young physicians have significantly less clinical experience than I believe I went through and they spend more years in training getting there. It's hard to be comfortable in a situation if you haven't been through it before no matter how many lectures you’ve had.

Anonymous said...

Hey Mike (58flyer). Nice to hear from you. I'm a big fan of yours at allnurses.com. Your experiences have helped me cope with bad experiences I've had. I'm also a big Joel Sherman fan. Thanks for understanding how I (we) feel. Most doctors I've seen and heard just don't seem to understand our need for dignity and modesty. Especially in regards to nurses and aids, particularly the young females with little or no medical training (receptionists, etc.)

Anonymous said...

If female doctors or nurses feel OK about bringing their secretaries or receptionists into an examination of a male patient, why not just ask the male janitor or the guy that delivers the bottled water? They would probably be just as qualified for the job as a receptionist would be and much less embarrassing to the male patients.

Joel Sherman said...

My feelings on the use of chaperones are clear, and I would refuse to have chaperones present, especially opposite gender, but really anyone. It's a violation of my privacy and it shows that the doctor is not comfortable with me.
But having said that, a receptionist working for the physician and a janitor are not the same thing. A receptionist theoretically knows she has to uphold patient privacy and could be fired if she doesn't. If she's being used as a receptionist, she should be trained for it. Does it always happen? -probably not, but it is still not the same as bringing in an outside person.

Anonymous said...

To Catherine
I also appreciate what you are doing and was also impressed with the way you were able to accept a little constructive criticism.

To Mike
I remember the story of your bad experience on allnurses.com. I was pleasantly surprised by how many nurses sympethised with your terrible experience. That really impressed me that so many of them seemed shocked and upset and apologized as a representative of the nursing profession and guarenteed that it wouldn't happen to other guys on their shift.

Anonymous said...

leemac - I couldn't have said it better myself. If I feel humiliated with the doctor giving an intimate exam or procedure, a chaparon (male or female) is just going to double or triple my humiliation.

By the way, I think I'm going to move to Great Britain. They seem to understand it much better than here in the U.S.

Anonymous said...

I think the analogy of using the janitor was simply sarcasim but goes to the point of "we are all professionals here". A receptionist trained in confidentiality is not the same as a "professional" who has a medical benefit to the patient. As in the past financial benefit for the provider trumps modesty and comfort for the paitent. So while one may argue the receptionist training to not disclose makes it better, it does so only for the provider, not the patient, and she has no more right in the exam room than the janitor. If the doctor doesn't feel comfortable with the patient...be honest and say so, and if they are going to bring in someone for thier comfort, the paitent needs to be advised and have the choice for finding a provider who is comfortable with them or will provide same gender chaperones. This is about money and protection of the dr. not the patient, they can at least be honest...alan

Joel Sherman said...

I have a somewhat different take on the subject Alan. Almost by definition a chaperone has no medical benefit for the patient, though Catherine has pointed out to me that it’s not true for the minority of women patients who actually request a chaperone. If a chaperone is actually used for the patient's comfort, then they can be of help. But that scenario is only rarely applicable to a male patient for whom the chaperone is more likely to decrease the patient's comfort.
Further chaperones are not about financial gain for the physician. It's about legal protection, and for women physicians, about their comfort level with the patient. But women practitioners who use chaperones extensively for male patients (and they are in a minority) lose money from the practice. It is expensive to pay people to stand around and watch. You can't bill for a chaperone's time.

MER said...

I think we're missing a major point here. Modesty is one issue, and an important one that needs to be dealt with. But the other issue is this:
Many of these chaperones are not really chaperones. They are witnesses. There's a difference. As Joel says, the main purpose of a chaperone is for the comfort of the patient. So -- if a patient doesn't want a chaperone but the doctor insists, we're not talking about a chaperone. The doctor wants a witness.
Secondly, this "witness" is a paid employee of the doctor. Can you imagine a lawyer cross examining one of these paid employee "witnesses" it court? Can you imagine you on the jury judging the credibility of a supposed chaperone, actual witness who has been paid by the person for whom she now testifying for?
I don't know how these situations turn out in a real court situation. Frankly, I can't see any benefit of a paid employee of a doctor acting as an "impartial" chaperone or witness. This is even a problem with patient advocates in hosptials. They're supposed to be advocating for the patient but they're being paid by the hospital. Nurses even have conflicts of interst in this regard. They are supposed to be patient advocates, and most of the really try to do a good job at that, bless them. But it's difficult when you have to go up against your employer to advocate for the patient.
When push comes to shove, these chaperones/advocates/witnesses know on which side the bread is buttered.

Anonymous said...

Dr. Sherman, I agree with most of your reply, I was a little to general with my observations. If the Chaperone is there for the patient comfort it is totally different and benefits the patient. This is I would think almost exclusively the case with female patients and is almost exclusively female (same gender) chaperones. I also equate financial and legal as similar, though failed to acknowledge there are serious aspects that effect a provider beyond the dollar amounts involved in allegations of this type. The non dollar costs are probably even greater. That said, this is not the case with a female Dr. and male patient, the differences are stark. The chaperone with a female Dr. are not likely to be to prevent unfounded allegations, but more for the personal comfort of the Dr. and the comfort of the patient becomes compromised as the gender of the chaperone is almost exclusively female. Personally I feel if a female provider does not feel comfortable with treating male patients alone, they should limit their practice to females, should incur the extra expense of hiring a male Chaperone, or atleast make it known to male patients upfront before they accept them as a patient. To bring in a second female under the guise of needing an assistant is deception. If it is for thier benefit they need to at a minimum, do everything they can to make it acceptable to patient, be willing to incure the cost, and be honest about it...alan

Joel Sherman said...

MER,
I agree that a paid employee is not perhaps the best witness for a doctor, but it is very rare that a complaint has been brought if a chaperone was present. They serve the purpose adequately. When a doctor has been disciplined and a chaperone has been mandated, a few states have required that they approve the chaperone who is being used.
Alan, now we agree. Indeed the use of chaperones by male and female physicians has a completely different dynamic. Men use them overwhelmingly for legal protection, though somewhat less than half their patients actually want them. But as the chaperones are always same gender, patients rarely object.
Women physicians use them predominately for their own comfort and not for legal protection though clearly very few of their patients want them. I personally agree that women physicians who are not comfortable seeing men shouldn't see them. In fact it is common for women physicians to specialize in 'women's health.' How many men specialize in 'men's health?' Only urologists come close, and many of the few female urologists (under 10%) actually specialize in women's urology.

Anonymous said...

To anonymous of 10/26 @1147AM and 10/26 @1241PM; thanks for the kind words. We need to stick together on these issues. It was enlightening that the nurses on allnurses were appalled at the thought of harming a patient, but what was also enlightening was finding that a number of nurses had heard of this practice.


Mike (58flyer)

Anonymous said...

Many female gynocologists also bring a female chaperone into the room even though they are examing a female patient. Male doctors examing men also bring in a chaperone even though they are the same sex as the patient. You'd think with a same sex patients there would be some leeway but it doesn't exist even in these situations. All doctors are afraid of being sued so they keep the extra ears and eyes in the room to try and offset it. It's a sad truth.

I would urge anyone male or female who doesn't want a chaperone to speak with the doctor before the exam takes place when fully clothed so as not to be in a vulnerable state. As the request isn't made too often the doctor might be taken aback but stick to your guns. Tell the doctor you feel more comfortable with a totally private exam. If they state they will be assisting ask what exactly they will be doing. The doctor can take their own notes or put the swab into an envelope themself.

If it is a procedure an assistant will be needed. I would not be afraid to ask the credentials of the person coming into the room. I would be okay with an actual nurse assisting but wouldn't be okay with the office manager coming in to assist. They aren't medically trained and that's an invasion of my privacy.

Joel Sherman said...

Yes, it's common for woman examiners to use chaperones for pelvic exams. If they're doing pap smears or other procedures it helps to have an assistant.
But I don't think it's at all common for male physicians to use chaperones for male genital exams though it certainly does happen. Do you have any reference for that statement? Unfortunately some doctors feel the need for chaperones most acutely when dealing with adolescents, just when the patient is the least emotionally equipped to handle another observer. This is justified on the basis that adolescents don't know what to expect and can more easily misinterpret the physician’s actions. So I guess it's easier to bring a witness into the exam room rather than carefully explain what the physician is going to do ahead of time which is how the situation should be handled.
I agree with your suggestions for how the patient should handle the situation and your emphasis on privacy.

Anonymous said...

In reading this site and Dr. Bernsteins's site I have seen many men having female nurses in exam rooms for male intimate exams even when the doctor was male. One patient asked the nurse to leave during a DRE and the male doctor was surprised. Others have had them in their for skin checks including the genitals and hernia exams also. I should however clarify that many times it's just for the doctor's convenience so they don't have to take their own notes. That's completely uncalled for if the patient is uncomfortable.

I am never in favor of the chaperone being of the opposite sex of the patient. In that case the doctor can't even pretend it's for the patient's comfort. It's not. Patients need to speak up and then walk out in instances such as these if it upsets them and they don't approve.

If I had teens of either sex would ask them if they would prefer a same sex provider. I would also ask if they'd like me or their father to stay in the room with them during their exam for their comfort. If my son said they wanted only males in the room I would make that happen and same for my daughters. It is up to the parents to take control and see that needs are met. If the doctor didn't understand why my son didn't want a female nurse in there for a hernia check they wouldn't be the doctor for us. I would want the doctor's office to be a place of comfort for my child not one of embarassment and shame.

Joel Sherman said...

Anonymous, it's hard to judge how common a problem is from this and Bernstein's blog. No way of knowing how representative the responses are. I still think it's rare for a male physician to use a chaperone for a male patient, though of course it's not rare if they are an 'assistant' which may only mean they take notes. I certainly wouldn't like that scene.
But you are to be commended for helping your kids through the system. Few parents are able to do that.

Anonymous said...

I agree many are termed assistants but either way it still comes down to having extra eyes and ears in the room for the doctor's benefit not the patient's comfort. If it is an actual procedure the doctor will need assistance and everyone should understand that, but in a routine skin check leave the assistant/chaperone out of the room and take your own notes.

And I am all for the doctor's having some say in regards to chaperones for opposite sex exams because I see it as a two way street. My urologist has a curtain and if you don't want extra eyes during the exam he closes it around you. The nurse stands outside it. I was impressed he found a compromise between protecting himself which is a valid concern, and providing patient comfort as well.

MER said...

I would suggest that this is also an issue of "informed" consent. Not being informed that a "chaperone," especially of the opposite gender, will be in the room with the doctor, seems to me a violation of this important principle.

Just because a patient doesn't object after not being informed ahead of time, doesn't mean they were informed or that they consent. A patient should be told at the time of the appointment, especially if the doctor has no intention of allowing the exam to be conducted with him/her alone.

For a patient to make an appointment without being informed, then to show up at an appointment uninformed of this situation, then fill out forms and not be informed by the receptionist, then be escourted into the room with a nurse or medical assistant without being informed,then told to undress and put on a gown without being informed, then all of a sudden facing a situation where the doctor and the female nurse come into the exam room with the expectation that consent has been given -- that seems untenable to me. This is a breach of ethics and an example of poor judgement and failed communication.

Joel Sherman said...

I can't imagine why a male urologist would want to have a chaperone present for a male exam. In truth, he hardly needs any protection and it's a significant office expense. But as you describe it, the situation is acceptable assuming she is not present for the history. Not too many men are comfortable with extra ears hearing their urologic problems.
MER, if you refer above you will actually see in my posts that the AMA recommends that permission be obtained whenever an observer is present for an exam. They conveniently ignore their own recommendation however when it comes to the use of chaperones.

Joel Sherman said...

Here's a nice commentary about the use of chaperones from another British journal (of course).
It's a thorough review of the problems and practices.

Joel Sherman said...

Here's a proposed law in Brazil mandating that all for all medical and dental exams on women that the presence of a female chaperone be made mandatory.
I find this proposal extraordinary. I can't imagine what the frequency of abuse is that could make such a law plausible or needed.
I know of no jurisdiction in the US where chaperones are mandated by law for any exam even though they may be strongly recommended.

Anonymous said...

I don't understand how anyone can be talked into consenting to a chaperon against their will. If a doctor I go to insists on having someone else in the room and I can't talk him out of it I simply begin to get dressed. Never once have I ever had to go through with it (leaving).

There is no way he can truly justify having a nurse or assistant present for a simple exam(why does it always have to be a woman?). You don't have to put up with it.

I've read probably 25 or 30 times on this thread and others of somebody giving the excellent advice of simply informing the doctor, nurse or tech that a chaperon is unnacceptable. As are female nurses, sonographers or assistants that try to perform or observe intimate exams or procedures. Yet it seems that very few actually do it. I would never put up with it and neither should any of you.

Joel Sherman said...

I certainly agree with you with the caveats that we are referring only to routine exams on men with opposite gender chaperones. On female patients, chaperones may be necessary, but they are almost never opposite gender.
For procedures you may not realistically have a choice, as same gender may not be available or you'd have to arrange it when you made the appointment. Not many guys are willing to submit themselves to potential ridicule by asking.

Anonymous said...

I'm not sure who wrote this article but one paragraph caught my eye. It concerns the use of chaperones. On page 20 the author states "Obtaining a chaperone is not a problem in our practice. When a skilled medical person (e.g. nurse, medical assistant) is not available, we simply prepare all the equipment ourselves and ask an employee of the hospital or clinic (e.g. secretary, housekeeping, billing person, etc) to serve as a chaperone as long as the patient doesn't object."

We all know from hearing and reading about so many experiences that most patients don't dare object. Here is the url if anybody is interested:

http://www.radcliffe-oxford.com/Books/samplechapter/767X/LegalIssuesch1-3fbb3380rdz.pdf

Earlier in the article he discusses the importance of using chaperones, for the doctor's benefit.

MER said...

That's an extremely interesting chapter from a book. Does anyone know what book it's from?

Earlier on the writer does say that chaperones of the patients gender should be used. But then, when he talks about bringing in anyone available to chaperone if a nurse or med assistant isn't available, he drifts off into questionable, I believe potentially unethical areas. As the last poster stated, he said he would do this if the patient does not object -- but it doesn't state that the patient is actually asked. And again we seem to have the assumption that if the patient does't speak up everything is just fine.

Still, this is an excellent chapter to read for everyone on these blogs. It does give a medical perspective, and it helps patients understand better why a doctor does need to see and touch a patient's exposed body to really do his or her job.

I do have a problem with patients who, under any circumstances, won't let a doctor see or touch them unclothed. I really believe these patients are in the minority. For most patients, it's mostly a matter of privacy, modesty, who else is in the room, chaperones, and other assistants of the opposite gender. Most reasonable patients will let doctors do their work if they feel comfortable with their privacy and modesty.

Joel Sherman said...

Thanks for that reference. Do you by any chance have more info such as the name and author of the book? Is it a man?
I agree MER that there is a reference to using same gender chaperones which is not stressed later on. Maybe they don't apply it to male patients given the comment that they'll use nearly anyone, all of whom would appear to likely be women. Of course they may never use patients for men. Can't guess from what I've read.
But I still firmly believe that using non medically trained personnel is abusive. I would not permit it if I were a patient.

Anonymous said...

Sorry Joel, I googled

http://www.radcliffe-oxford.com/Books/samplechapter/767X/LegalIssuesch1-3fbb3380rdz.pdf

and you've seen what I've seen. I agree with you 100% when you said that using non medically trained personnel is abusive. I would never put up with it either.

MER said...

Here an abstract of a relative recent study of chaperone preference. Note that the study apparently doesn't ask about the gender of the chaperone, which I find to be quite telling. Note also that most doctors didn't ask permission to use chaperones yet most patients which they had. Quite interesting

Here's the abstract:

Southern Medical Journal:Volume 101(1)January 2008pp 24-28
Chaperones for Rectal and Genital Examinations in the Emergency Department: What do Patients and Physicians Want?
[Original Article]
Santen, Sally A. MD; Seth, Naveen MD; Hemphill, Robin R. MD, MPH; Wrenn, Keith D. MD

From the Department of Emergency Medicine, Vanderbilt School of Medicine, Nashville, Tennessee; the Department of Emergency Medicine, University at Buffalo School of Medicine, Buffalo, New York; and the Healthcare Solutions Group, Vanderbilt School of Medicine, Nashville, Tennessee.

There was no support of this study. None of the authors have conflict of interest. This study was approved by the IRB.

Reprint requests to Dr. Sally Santen, 703 Oxford House, Vanderbilt School of Medicine, Nashville, TN 37232-4700. Email: sally.santen@vanderbilt.edu

Accepted May 31, 2007.

Please see C. Shawn Tracy and Ross E.G. Upshur's editorial on page 9 of this issue.

Abstract
Background: The objective of this study was to compare patients' preferences and physicians' practice for the presence of chaperones during genitourinary examinations.

Methods: A survey of 163 emergency department patients and 52 physicians was used to evaluate patients' preferences and physicians' practices for the presence and gender of a chaperone during genital examinations.

Results: Most male patients (88%) did not care about the presence of a chaperone. Only 47% of female patients preferred a chaperone when a pelvic examination was to be performed by a male physician and only 26% preferred a chaperone with a female physician. One hundred percent of male and most female physicians (92%) used a chaperone for pelvic examinations. Most physicians do not ask patients whether they want a chaperone; however, most patients would like to be asked.

Conclusions: We conclude there is a discrepancy between what physicians do and what their patients desire.

Key Points

* Most male patients do not care about the presence of a chaperone.

* About half of female patients want a chaperone with a male physician and a quarter with a female physician.

* Nearly all physicians use a chaperone for pelvic examinations.

* There is a discrepancy between what physicians do and what their patients may desire.

Here's the link:

http://www.smajournalonline.com/pt/re/smj/abstract.00007611-200801000-00015.htm;jsessionid=JxDBvCG2lnZq3Q8m3t7xmYwmywBwfYrQK4ty7zJ6W1G15TR4xwQh!1689917466!181195629!8091!-1

Joel Sherman said...

I have the full article MER. I don't really know how to reconcile it with the results of the mass of British studies above. They did ask about gender preferences for the chaperone. The article specifically says that "most male patients (83+ %) felt that either a male or female chaperone was acceptable with either gender of physician for both testicular and rectal examinations." Over 80% did not care about the presence of a chaperone though most wanted to be asked.
Questions I had about the study concerned mostly the ER setting where I believe patients are less concerned with privacy than they would be for routine care. Also a significant percentage of the men in particular had not undergone a rectal/genital exam; the percentage is not given. These were apparently patients who were in the ER for all kinds or reason, not specifically for 'intimate' concerns.
This was by the way a large urban hospital with a 25% African American population and 67% Caucasian. Not sure how the demographics affect it either. Average age was 37, so it is a population not relevant to adolescents who I'm sure would give different results. I think it would be perhaps more relevant to have had done the study with patients who had just undergone intimate exams with or without the presence of chaperones to find out what they preferred. But the ER setting is very different from an office where people expect personal care.

MER said...

Thanks for the further explanation, Joel. Frankly, before I fully accept studies like these, I really need to know even more details, especially the questions that were asked, precisely how they were worded.

The irony is, I believe, that a prime reason for a chaperone should be for the patient's comfort. Of course, we know the primary reason today is to protect the caregiver. If patient comfort were a prime motive for chaperones, there would be no question about whether to ask the patient. Unless it is just assumed that patients are most always more comfortable with a chaperone.

Were female patients asked specifically if they objected to a male chaperone?

With studies like this, I also want to know more about the researchers' agenda. What beliefs and assumptions regarding chaperones do they have going into the study. What was the specific reason for the study?

If the study was done by researchers who held a gender neutrality (or gender doesn't or shouldn't matter) world view, the I'd be suspicious. Anyway to get this kind of information?

Joel Sherman said...

MER: If the study was done by researchers who held a gender neutrality (or gender doesn't or shouldn't matter) world view, the I'd be suspicious. Anyway to get this kind of information?

Maybe MER. You'd have to research the authors and look up all their published works. If you go to their professional website you might find some useful information. If they are prominent, you'll find enough info, but most of the time you won't. You can sometimes contact the authors and ask for further info directly. Dr Santeen's email from Vanderbilt is listed.

Anonymous said...

That study has to be tainted somehow. 83%? How ridiculous. Like Joel and MER I think there has to be flaws. I will never accept the "fact" that 83% of the men anywhere in the world would accept chaperones, particularly female chaperones..

Anonymous said...

The figure of 83% cited above is obviously a nonsense. My research shows that 108% of men do care! There another nonsense figure invented. The questions which were asked, the timing of the questions, the way they were posed, the agenda of the questioners are all factors which would need clear elucidation. We are expected to believe 83% without question....

By the way, there are fairies at the bottom my garden, 95% of donkeys asked said so.

Joel Sherman said...

Well I'm doubtful of the results too as I've stated but I doubt that they're imaginary. The inner city urban setting and the ER setting likely contributed to the surprising results. The racial breakdown of the participants may have also contributed as I've noted under the religion and race thread.
One other consideration may be social class in general which we have not referenced up to now. The expectation of privacy may vary substantially in the middle and upper classes where most people are now raised with private bedrooms and bathrooms. That would be very different from some inner city areas where large families living in smaller spaces with one bathroom afford little privacy to their kids and adults alike. But I'm just speculating.
I'll see if I can find out more about how class affects the expectation of privacy.

Anonymous said...

one has to be wary of numbers like this. The fact that they are taken at an ER where the expectation of privacy is less and the likelyhood of life threatening or serious injury or illness probably influences the numbers. Likewise if its in the states ER's are often the avenue for people without the ability to pay or get care...I would assume in those cases one accepts what is handed to them more easily.
I would assume that if I asked that very question(s) at a domestic abuse center, a strip club, convent, and a massage parlor... I might get a varied response as well....alan

Anonymous said...

I am not sure if this is the correct topic under which to post but I did notice yesterday on my doctor's website a notice ot the effect that as the surgery has strong link swith a local medical school that sometimes 3rd or 4th year medical students attend examinations and if the patient does not want him or her there they should inform the receptionist and the student will leave the room.
Personally in a case like this I would like to think I would overcome my shyness in an effort to help the student gain useful experience.

Joel Sherman said...

Granting permission for students to observe is fine. They have to learn somewhere. I have no problem with it except perhaps if it is an intimate exam before multiple students. Would depend on the situation. There is of course a big difference here between medical students and residents. The latter are part of the team and should be routinely permitted.
The only valid complaint is that most teaching institutions have a patient give blanket consent upon entry. You're not really bound by that, but if you don't want students around, you should really go to a non teaching institution for your care.

Anonymous said...

"if the patient does not want him or her there they should inform the receptionist and the student will leave the room"


Do you mean that you should inform the receptionist before you go in? What if you aren't expecting there to be a student in the room? Does the receptionist mention that to everyone beforehand? I suppose if you weren't expecting them you could just ask them to leave yourself.

I wouldn't have a problem with a medical student watching as long as my pants don't come off. If they come off, all students, techs, assistants and nurses would have to leave.

What is the difference between a student and a resident?

DF

Joel Sherman said...

Students are medical students. They have not finished their training , are not licensed, and should not be called 'doctor' legally. Residents have finished 4 years of medical school and can be licensed as physicians. They are there to further their training. They often provide most of the care in teaching hospitals with supervising physicians working in an advisory mode.
The anonymous comment about notifying the receptionist is only applicable to that particular office.

Anonymous said...

I was told I could bring a chaperone of my choice to a testicular ultrasound...they were kinda shocked when I told them I did not want an audience...I was just trying to get a male tech...a chaperone does nothing for my embarrassment except to increase it.. if a doctor does not trust me (any provider actually) and needs a chaperone witness..they also need another patient...
I sure hope that more providers will start coming to an dcommenting on your and Dr. Bernstein's blogs
leemac

Joel Sherman said...

Leemac, are you saying that you asked for a male tech and instead they offered you a chaperone?
If so, it's amazing how offices can be so clueless that many men have the same modesty and privacy concerns as women. An example above is that the very well meaning and concerned Catherine Dube recommended that if a young guy was embarrassed by an exam that a woman chaperone be brought in, the very worst solution imaginable. Imagine someone recommending that a male chaperone be brought in to watch a girl's exam to ease her embarrassment.
We'll just have to keep on trying to educate people.

Anonymous said...

They said I could bring along anyone I wanted or they would provide one.(another female)... I gutted it out by myself. I now know I could have found a different facility that would accomodate me and had my PCP issue a prescription to that place...I had earleir been told my insurance demanded the place I was sent to...but it turned out that it was one of several it recognises and will pay...Yes..they only made it worse for me...The last thing I wanted was an audience , especially one of their office ladies or female techs....The only concession I got was I manged to limit exposure by draping myself so that only my scrotum was visible...but I really wanted to crawl under that table when the twenty-something female tech came in and started..
leemac

Joel Sherman said...

Leemac, if the exam wasn't urgent, I'd try complaining to the insurance company for another referral to a place that would do it either with a male tech, they do exist, or lacking that, without a chaperone.
If there were more refusals, they would accommodate you readily enough. Some doctors' offices would be willing to make the call for you.
I personally would not allow a chaperone to be present. It's outrageous in my opinion to sacrifice the patient's privacy in these circumstances when the risk to them is so small.

Anonymous said...

So what are your opinions about an openly homosexual doctor, nurse, etc. concerning chaperones? If a gay male doctor or nurse was performing an intimate exam on a female patient would he need a chaperone? Would you guys that don't want a female nurse or assistant present during an embarrassing exam accept a lesbian nurse? Would modest women accept a gay male nurse?

GL

Joel Sherman said...

The question comes up, but I don't think it is relevant. A patient hardly ever knows the sexual proclivities of their examiner.
Doctors use chaperones for legal protection against accusations not because they're afraid they're going to molest someone. The ones who might molest you, won't bring in a chaperone.
A male doing a pelvic exam on a woman is generally considered to need a chaperone present for their own protection. In every other instance, it is optional. For other intimate exams a chaperone can or should be offered depending on the situation. A doctor who tells you that it is required in any other situation, is telling you that he/she doesn't trust you. If you as a patient don't trust the doctor for whatever reason, by all means ask for a chaperone. But you'd be better off going to someone you do trust.

Anonymous said...

As a woman who has had horrific experiences with medical staff, I would LOVE to have the choice of whether to have a chaperone present. Personally, I am so bothered by the presence of a third party that I don't seek out medical care, because I know that my needs or desires will not be respected.
Yeppers...there's been some trauma in my past...all of it in front of onlookers--female onlookers. Do you think for a moment I want another woman watching me at my most vulnerable? Absolutely not. I would KILL for a practitioner who would respect me enough to allow me to tough it out without an audience. And I'm sure my husband would appreciate the fact that he would sleep undisturbed after my appointments, instead of waking up because of the nightmares these scenarios cause.

Joel Sherman said...

You’re not alone anonymous. If you read through the studies from the UK and here you would find that a substantial percentage of women prefer not to have onlookers of any gender. Most of the readers of this board likely don't realize that most women too are reluctant to speak up and make their preferences known. But don't let it stop you from having care. Tell the provider your preference up front. Certainly the majority of women providers are willing to do pelvics without chaperones. Men may be more reluctant because of the legal risk, but you can always offer to sign a release to that effect. My wife's gynecologist, a male, recently did her exam without a nurse present because none was available at the time. It's not a problem when there is a strong physician patient relationship and they trust each other.

MER said...

This is from an Australian medical site. This link from the site is discussing chaperones. Read this:

"Ideally, permission needs to be sought when the patient makes an appointment, or failing that, when they arrive at reception. It is not acceptable to ask permission in the consulting room, as some patients may feel 'ambushed' and unable to refuse."

I've never read this acknowledged on any medical site. This is an example of a secret known fact in medicine, but a hidden fact. Doctors and nurses know about the "ambushing" strategy. They just don't talk about it.

The link for this is:
http://www.racgp.org.au/standards/213

Joel Sherman said...

MER, the problem in the US goes deeper than warning patients before hand. In this country patients aren't warned at all. Permission for a chaperone to be present is rarely asked at all.
I've documented this above in this thread. AMA guidelines say that whenever a clinically unnecessary person is present during an exam, the patient be asked and permission granted. But their specific guidelines for chaperones don't mention this at all and few do it. I sent the AMA a letter about this long ago, but never received a response. They are far more worried about protecting the doctor than they are about the patient in this situation.

MER said...

Joel:

How does one define what is "clinically" necessary? Is there any kind of objective definition, or can it be played with to mean whatever the doctor wants it to mean?

Joel Sherman said...

Here's the actual quote MER:


E-5.0591 Patient Privacy and Outside Observers to the Clinical Encounter

Outside observers are individuals who are present during patient-physician encounters and are neither members of a health care team nor enrolled in an educational program for health professionals such as medical students. Physicians are ethically and legally responsible for safeguarding patient privacy and, therefore, must inform outside observers about medical standards of confidentiality and require them to agree to these standards. Outside observers may be present during the medical encounter only with the patient's explicit agreement. Physicians should avoid situations in which an outside observer’s presence may negatively influence the medical interaction and compromise care. The presence of outside observers during encounters between physicians and patients who lack decision-making capacity should not be permitted, except under rare circumstances and with consent of the parent or legal guardian. Physicians should not accept payment from outside observers because accepting such payment may undermine the patient-physician relationship. (I, IV, VIII) Issued November 2005 based on the report "Patient Privacy and Outside Observers to the Clinical Encounter," adopted June 2005.


I'm sure the AMA would not consider a chaperone to be an 'outside observer'. Though you'd think that their definition would exclude secretaries for example.

Anonymous said...

I agree with Joel Sherman. There aren’t state requires chaperones to be present in exam room during the examination and patient have choice to refuse one. That`s may be right for advanced democracies at West Europe, Britain and United States. But it`s similarly true that there are so many totalitarian, ex–totalitarian and religious–based countries in Eastern Europe, Asia and Latin America where certain services enforce rules, norms and traditions at variance with some human rights and people`s privacy. Most medical offices force policy that requires parent or guardian to present in exam room and witness examination regardless of gender of the patient. Commonly, this is the mother, something who put preteen and teen boys in rather uncomfortable position.

Anonymous said...

Excellent comment MER. I've heard and read so many accounts where an "ambushing" strategy was used. The providers understood the fact that when the patients are asked right in front of the chaperone/nurse/med student the patients hardly ever objected when they probably would have without that person present at the time. They didn't feel guilty about it at all. Very cruel and underhanded.

MER said...

This "ambushing" is a strategy. I don't think it's taught in the curriculum, but it's learned on the job. In fairness to doctors and nurses, there's a line between unconscious routine and conscious strategy. Where that line is, it's difficult to tell. But I don't think I'm being unfair to say that at least some medical professionals know exactly what they doing when they surprise patients with chaperones or other observers. And I think that some female doctors who don't feel comfortable doing intimate exams on males. feel more comfortable themselves if they have a female chaperone. I know some people have a hard time with what I'm about to say -- but this is also about control. That female doctors will feel more in control of the situation if the man is embarrassed to the extent that he'll just shut up and do what he's told.

Take away people's clothes, make them naked, force them to be seen by the opposite gender -- and you are in control of the situation. This strategy is during war, has been used in group physical exams for men, as part of interrigation strategies, and as part of torture methods. I know medical professionals resent it when I mention this. But they need to realize how psychologically threatening it is to be exposed naked in any kind of situation, especially to the opposite gender. If doctors and nurses and techs can't establish an ambiance of trust and comfort, they might as well be operating a prison camp.

I recently I visited a doctor to have him look at something. Nothing intimate. He came into the room with another doctor and asked if he could observe. Of course, I said yes. No problem. I've had other doctors have their nurse right at the beginning ask me if I would mind a medical student observing. That's more appropriate.

What I'm saying is that if doctors and nurses just get in the routine or habit of bringing the observer or chaperone into the room, perhaps for non intimate exams -- the just continue that habit or routine even when the exam becomes intimate. they lose sight of the difference. For some, it just becomes an unconscious bad habit. For others, it's a strategy to intimidate the patient into doing what they're told to do. It makes the exam go better for them. The focus isn't on the patient.

Joel Sherman said...

I don't know that 'ambushing' is as much a conscious strategy as a habit. Don't know the statistics, but I'm sure very few patients refuse. Providers just get used to asking for a perfunctory permission.
I'd bet this happens far more often in hospitals where doctors may be rounding in large groups or teams that may include a variety of people such as students, nurses, pharmacists, and dieticians. Aides would only rarely be along. Most people can accept lessened privacy in hospitals. Note none of these people are chaperones who are rarely used in hospitals.
In private offices patients have a much greater expectation of privacy. But most providers never ask if an actual chaperone is OK, they just bring them in.

MER said...

Joel, you write: "Most people can accept lessened privacy in hospitals."

Maybe. Maybe not. We don't know. I would question the words "most" and "accept." I would say some patients "tolerate" lessened privacy. Note the comments I recently made about informed consent. What conditions are necessary for the kind of agreement we're talking about? If a large group of doctors, nurses, etc. barge into a patient's room and start doing an intimate exam, and the patient isn't asked and doesn't say anything, is that acceptance?

I question whether most patients accept all kinds of lessened privacy in a hospital situation. They may be convinced of the necessity. But that takes time. It takes one on one communication. It takes trust. And we all know the problem with time in these situations.

Joel Sherman said...

MER, your comments here fit into Art Stump's cancer thread well. I think he has the right emphasis. How well people accept modesty and privacy violations depends in large measure as to how sick they are. Obviously patients in hospitals can be very ill and dependent on others and are much less likely to complain. But I'd go beyond that, they are also less likely to care though that is difficult to document.
Obviously some people do care including most readers of these blogs. But most people in this situation are most concerned about regaining their health.

MER said...

I essentially agree with you, Joel, but I don't think it's an either/or situation. I think "health" includes physical, psychological and spiritual. They are difficult to separate. Although a patient may be focused on surviving, his or her psychological state as to modesty is important, too. And it may be even more important than we think because the patient may feel that speaking up will somehow influence his relationship with the care-giving team.
I think we need to think of the whole person, not just the body. That's what's often missing here. In ICU cases where patients are unnecessarily exposed because the care team thinks he/she isn't awake -- that shows thoughtlessness. Many studies have shown that patients are often more aware of what's going on than what people think.
We've got to actually, not just theoritically, accept the hollistic view of patient treatment. The whole person is being treated. Survival just doesn't mean bodily survival. There are psychological and spiritual elements related to survival, too. You can't really separate them.

PR said...

If I ever needed a gyn exam, I'd see a woman.
I would find that level of exposure VERY DIFFICULT.
I would be the female doctor and that's it.
To think some women have a male Dr and another observer makes me shiver.
In Australia, many doctors don't use chaperones. Probably one of the reasons we do have quite a few problems.
Patient Privacy v Your Safety
I'd go with the female and avoid all of these worries.

Anonymous said...

PR,

To fully appreciate a man's nightmare, imagine not only you that you had a male gyn, but that he brought in a male office manager or other male "medical assistant" to chaperone. This is common with female urologists. And although men try not to react, trust me, we're as mortified as you would be.

--rsl

PR said...

It's unacceptable whether the patient is male or female.
There are very few female urologists in Australia...I wonder whether the male urologists use male nurses.
No man in this country would need to see a female urologist.
As the chaperone thing doesn't happen more often than not and would never happen if you're seeing same sex doctor, I assume most male urologists would see you without an assistant.
Procedures and surgery would be different.
I think the accommodation of females probably stems from the assaults that have occurred over the years and the fact most/many women have felt threatened by males at some point in their lives. I certainly have had a few frightening situations with drunks approaching me and men behaving aggressively in groups.
I know some women are more aggressive sexually these days, but I haven't heard any of the men in my circle complaining about being touched inappropriately or being in fear.
Maybe...that's just my circle.

I think that was probably the start of the accommodation - of course, there were no female doctors in this country way back when, so women were just told not to be silly girls.
I think as female doctors appeared and there was a land rush to get on their books, the silly girl angle was initially stepped up, because the few female doctors were causing problems for the system - women being more outspoken about wanting a female doctor.
That forthrightness has increased as more and more female doctors appeared. I think the system just felt it was easier in the end, to acknowledge patient preference.
Now more than anything else, the accommodation is more about modesty than safety. (my take anyway)
I think men and women were level pegged in the modesty fight - we had male doctors and no choice, you had female nurses and no choice.
As more male nurses enter the profession, the problem will slowly dissolve...
Just keep your male nurses in your wards though...
I don't want them nursing me...for anything embarrassing anyway...
I don't mean to generalize, but when men have access to women, there are often problems. I was reading that even though male nurses only make up 9% of the profession here, more than half of the complaints relate to male nurses.
Some are their fault, some are misunderstandings and others are the system putting the nurses in an impossible position...like sending a male nurse to shower a 19 year old girl - just plain stupidity and bound to result in a complaint.
I think male nurses have to protect themselves from those complaints. If they don't see gender as an issue, I think their nursing career will be shortlived...you can't impose yourself on a patient - male or female. You may be a professional, but patient choice comes first when intimate care is involved...male and female.
If I can find the article on male nurses, I'll post it for your information.
Prue

Joel Sherman said...

I agree with you PR. Female urologists are uncommon, under 5% in practice, and many of them specialize in female incontinence or similar problems. No man has to see one except possibly in an emergency. But male urologists do use female assistants for procedures when they need assistance, though not generally as chaperones. I asked my urologist about it and he said for the most part they can't get male assistants.
You are also I'm sure correct that more male nurses percentage wise are accused of impropriety than women. But as you say the reasons are complex. Some of it is misunderstanding. Much of it is that men are loathe to complain; it is not macho to say you've been abused by a woman. Clearly on the average women feel more physically threatened than men do in most situations.
The male nurses I know are great, and I have let them take care of my wife.

Anonymous said...

"you can't impose yourself on a patient - male or female. You may be a professional, but patient choice comes first when intimate care is involved...male and female."

Tell that to the female nurses Prue. I agree with you completely but not all female nurses are saints either. If I were a male nurse or assistant I would ALWAYS ask my female patients if they would be more comfortable with a woman, even if it got me fired. I wouldn't put them on the spot either, or act offended or condescending.

I expect the same from my female nurses, although probably 99 out of 100 wouldn't do it. I would just be happy if they didn't throw a temper tantrum or try to belittle me. While I acknowledge that unfair things happen to female patients everyday, I don't think they come close to the amount of problems male patients have with female nurses.

Anonymous said...

one thing that is seldom addressed is women are more likely to file a complaint warrented or not, becuause it is socially acceptable. I read an article about complaints of groping of airline travelers going through screenings. Not surprisingly they were over whelmingly females filing the complaints...the surprise...they were screened by other females...would anyone take a males complaint seriously, automatically the male nurse, screener is assumed guilty until they prove themesleves innocent. an interesting fact, more female guards are disciplined for having sex with inmates than males, however male guards recieve harsher penalties and get more attention as sex between a male gaurd and female inmate is more likely to be "assumed" coericed and female gaurd/male inmate is assumed to be consensual, even though it is the power dynamics that define each event. Chaparones are along the same line, even though with cross gender Chaperones the odds are the Caperone will be female...males complaining will not be taken seriously....only when we continue to voice and press the issue will it change....the answer is still for all patients to unite and stand for ALL paitents...alan

Joel Sherman said...

I agree with your comments, Alan. I was astounded to learn awhile ago about the prison situation. Yes, female prison guards are bigger offenders than the men. The story I came across from ABC news is given here. In fact I recently alluded to it in an editorial letter that was published. The original editorial was proposing that all male guards should be banned from female prisons, but the writer never mentioned the greater problem with female guards, and completely ignored the question as to how many of these 'rapes' are physically forced, coerced, or fully consensual. In fact very few are violent. Most violent prison rapes occur between male prisoners which is a much greater problem.
Sexual contact between prisoners and guards is illegal in all states and a felony in some no matter what the gender. It's not rare though for female guards to be prosecuted for it.

Anonymous said...

The easy solution for cross gender chaperone problems is REFUSE THEM. Actually, refuse ALL chaperone issues you are not comfortable with.

I don't know any statistics but I imagine that not many doctors will refuse to treat a patient under most conditions without a chaperone. Situations with male gynos or minors might be more strict though I guess.

LG

Anonymous said...

After reading everyone's posts, I have to say that I am thrilled to see that there are in fact doctors out there who have compassion and understanding regarding this particular issue as it relates to their patients feelings of modesty and rights to privacy. I had given up on ever going back to a doctor because of it. For the life of me, I cannot find a doctor willing to examine so much as my foot, without the presence of a chaperone.

Personally, I see no difference in the feelings and concerns of a male patient than that of a female patient in regards to humiliation. Nearly all of us, male and female, find it embarrassing enough to have to have any type of intimate exam by any doctor. And it doesn't matter if that doctor is male or female, nobody wants an audience and quite frankly, three is always a crowd IMHO. Also, it never fails that the doctor will ask questions that are extremely personal in nature while the chaperone is present. I'm sorry, but it is humiliating enough to even discuss certain things with your doctor, let alone being forced to answer in front of a third party. I am a 46 year old woman and I don't need some 20 year old, gum smacking, thumb twiddler in the room with me hearing all the intimate details of my body functions or at this point in my life, lack thereof LOL.

That being said, I can honestly say that I completely understand a male doctors concerns with being in a room with a female patient. We live in a sue happy society. Doctors feel they need a witness to their good behavior. And I am quite sure that doctors are falsely accused much more than actual inappropriate incidences occur. Nevertheless, this problem has prevented me from going to the doctor countless times and has made me drop many a doctor because of it.

Mrs. B.

Joel Sherman said...

Mrs. B,
I wanted to point out that it is never appropriate to have a chaperone present when the doctor is taking a history, especially about sensitive issues. The AMA clearly recognizes this in its guidelines re chaperones. (That's referenced somewhere above in this thread.)
You would be well within your rights to complain directly to the provider and ask the chaperone to leave.
If you've read all this thread, a surprising percentage of people are like you and prefer not to have a chaperone present under any circumstances though most male doctors would feel it necessary during an intimate exam on a woman. Even then if you have a long standing relationship with a physician and you're both mutually comfortable, the doctor may be willing to forgo a chaperone.

Joel Sherman said...

This blog which was first mentioned in the women's thread is also of interest for the comments made about chaperones. It talks (among other things) about how many women dislike the presence of same gender chaperones during pelvic exams. Most can accept that they are necessary if the physician is male, but see no reason for them being there if the doctor is female.

Anonymous said...

I know of a doctor who has just "come out of the closet" in 2007,and who for years has conducted rectal exams on men under fifty, over fifty and I know of one man who was only 31 at the time. He went to this doctor for a acid reflux condition and came out with a rectal exam. I have talked to many patients of this doctor, who before, the so called "coming out", has said, yes Dr. X and I are very intimate,of course, they would laugh about it and state that, It doesn't matter if I go in for a sinus infection or the flu, I will get a retal exam, even if I had just had one a month before. These men never knew that this Dr. was gay. Now, normally these exams are done once a year for white men over 50 and once a year for black me over 45. Would one not say that having a rectal exam before the age of 50,being a while male, with no know close family, ever having prostate cancer, not be sexual misconduct or better yet, just plain sexual rape. This male doctor never has a chaperone during these exams. He has even told one of his patients that he had a cute ass. What should one do with a doctor such as this??

Joel Sherman said...

Anon, the sexual orientation of the physician makes no clear difference. You could raise similar questions potentially for example about a woman physician who regularly did rectals on men. A rectal exam is not an assault. There may be appropriate reasons for doing them on younger men. You should ask if you have questions why an exam is being done.
Only the one comment seems inappropriate but even that is difficult to judge out of context. But clearly, if you're uncomfortable with any given physician, find another.

Anonymous said...

Joel,

"A rectal exam is not an assault"?

I would have thought it could be depending on the circumstances. If a patient really believed it was assault it should be reported. Simply moving to another Doctor is why some (a small number) of Doctors continue to practice and continue to assault patients.

(Not that I am saying that this applies in this case, as I suspect that an openly gay doctor might be more cautious rather than less.)

Chris

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Joel Sherman said...

I guess I'm amenable to flattery. The above site is basically commercial but may be of interest to some.

Anonymous said...

Thanks again Dr. Sherman for spending so much time helping us cope and learn.

Joel Sherman said...

Here's an article about the use of chaperones which presents some unusual views. The author states that a woman provider should be comfortable using a male assistant to do an exam. He also doesn't believe that chaperones are mandatory.
Several commenters disagreed with him.

MER said...

"Female physicians should feel comfortable with a male assistant for pelvic exams and gyn surgeries. The main issue is to have a second pair of hands for equipment and specimens."

His focus is completely on himself and his staff and what's comfortable and efficient for them. For him, the main issue of having a chaperone is an extra set of hands. Nothing about patient comfort.

I don't question his ability his ability as a doctor, or his dedication to his patients. But he's several French fries short of a complete order. Something's missing in his thinking process. There's absolutely no mention of whether the patient wants a chaperone or what gender the patient would prefer. I can just imagine how he would look at a male who wanted a male chaperone.

I do, however, make a distinctin between pelvic exams and gyn surgeries. But, again, we're back to respect enough for the patient to make the patient part of the treatment by giving the patient some choices.

Am I making too much of this? Is his attitude common do you think?

Anonymous said...

His view is uncommon in that while chaperones aren't mandatory in these situations most that do pelvic exams have one present. Rarely are they done without them. His focus in regards to not using them are time delays to other patients and finances. Many doctors would argue the cost of a lawsuit would outweigh saving the money upfront.

He should absolutely be asking his patients if they want a chaperone and document accordingly. It's not all about his wants and needs. He doesn't factor in their feelings at all. Many might not want one, but for those that do he could be leaving himself very vulnerable to an accusation against him.

Dr. Lisa

Joel Sherman said...

I agree with both MER & Dr Lisa. The focus should be on the patient and not how stated in that link.
I would point out that although everyone recommends patients be given their choice in asking for a chaperone to be present, rarely do you see the recommendation that patients be given the opportunity to refuse a chaperone. The AMA is silent on this completely. Studies linked to above, mainly from the UK but the US as well consistently show that many people prefer NOT to have chaperones present. This even includes a large percentage of women undergoing pelvic exams from male physicians. Men prefer not to have chaperones present in even higher numbers, not surprisingly as the chaperones are nearly always women. The AMA policy is meant to protect doctors, not patients.

Joel Sherman said...

Here's an ad from a Texas HIV clinic looking for volunteers to help. Among their duties would be to serve as chaperones.
Ideally chaperones should be patient advocates with medical knowledge. What does anyone think lay people are going to do except stand and gawk.

MER said...

That's interesting, Joel. I don't know how this would work -- but if I were running the program -- I would make sure these volunteers became close to the patients on many levels before they were offered as chaperones. Certainly they need some training in various medical areas. But, frankly, if I try to put myself in that situation as an AIDs patient, I would feel more comfortable with a volunteer that I knew and talked with every day as a chaperone, than someone who was just called in, someone I didn't know very well. Of course, although they're not saying it, this is obviously a cost cutting move, so they won't have to use cna's and nurses as volunteers. If using volunteers patients know helps make both genders more available, and makes the patient feel more safe, then I say look into this plan.
All of what I've said centers around patient comfort and patient choice. That's my focus. I realize that the medical community, and with good reason, needs to also focus on their own protection.

Joel Sherman said...

A brief article from the UK exploring the use of chaperones for genitourinary exams including gyn. Surprising to me is that 60% of women physicians used chaperones when doing pelvics but when the same exam was done by nurses, only 5% used chaperones.
My conclusion is that despite what recommendations you see, chaperones are overwhelmingly used for protection of the physician and not for the comfort of the patient.

Joel Sherman said...

An article about chaperone use in an older pediatric population. According to this abstract 99.6% of patients declined non-parental chaperones! Given that there were 236 patients, apparently only one accepted. Gender of the chaperones is not mentioned in the abstract.

Anonymous said...

Fascinating abstract for that study, Joel. Note that, at least in the abstract, gender wasn't even mentioned. That's an example of the "elephant in the room" syndrome. I've been reading the research on that - the Emperor's New Clothes syndrome. The fact that the concept of gender doesn't even come up in the abstract demonstrates how important it really is and that those who did the study don't want to talk about it. I could be wrong -- but that's my take at this point.
-- MER

Joel Sherman said...

Later I got the full article MER. They said that same gender chaperones weren't available so they left it out of the study. They didn't say this, but obviously male chaperones weren't available for the boys. Of course it seems to me too, that it doesn't make sense to study chaperones unless you're prepared to study the effect of the gender of the chaperone has on the patient.

Anonymous said...

Joel:

You see the key words there -- same gender chaperones "weren't available." Let's not find out whether same gender chaperones should be available. That would be a patient-focused study. Let's do a health care system-focused study. Same gender chaperones are just not available (for men and boys, anyway) -- and it would be too much trouble to make them available. So -- we begin with several possible premises.
-- Medical professionals are gender neutral and thus patients either don't care (an assumption that makes caregivers feel good) or, if they do care, they need to relearn not to care.
-- If they do care, we'll resocialize them. Most will comply anyway for reasons we've discussed on these blogs.
-- Most available chaperones are female, and it's more economical that way -- because we need female chaperones for males caregivers treating females, for legal reasons. We can't use male staff for that, so it's not economical to hire them.
-- It would be too expensive, time-consuming and inefficient to give patients real choices here. So, let's design a study where we control the kinds of choices patients can have, choices that are all designed to make life easier for us.
Now, I'm not saying these premises are necessarily conscious. That's how this elephant in the room syndrome works. We see but we don't acknowledge. After we don't acknowledge long enough we don't even see anymore. The elephant doesn't even exist for us.So -- let's do a study trying to avoid that whole subject.
I've just been reading a fascinating book on this very subject, not chaperones -- but why we don't discuss certain subjects and why we deny that we don't discuss certain subjects, and why the academic community doesn't even research these unspoken topics. There's a myth some believe that science isn't affected by this elephant in the room syndrome. That's just not true.

When I finish the book and digest it, I'll post some summaries that tie it into this whole modesty issue within the health community. The health care system either doesn't recognize this problem and/or, it does but pretends that it doesn't really exist -- or, in some cases really tries to deal with it to mitigate patient discomfort. What we need to do is find out where modesty concerns are being met, where patient dignity is being systematically respected in this area, and find how how it's being done. Then, use these examples for the rest of the health care community. Problem is, the health care system doesn't want to talk about this -- even those who are working hard to deal with it. You'd think they'd be proud that they were helping patients successfully with modesty issues. But it's a taboo subject, at least for a public forum.
MER

Joel Sherman said...

I don't know if the subject is really taboo. I think it's a combination of women providers not using chaperones very often with men, maybe 10% of the time. So the need is low; they probably use them more with women. Secondly it is indeed hard to hire men to have available for chaperone use. There aren't many male nurses and most don't work in private offices. Medical assisting doesn't pay well enough to interest many men. Thirdly and here I agree, it hasn't occurred to some doctors that many men would care what the gender of a chaperone is. They can be as off base as Catherine Dube above who published that if a male adolescent is uncomfortable with an intimate exam you should bring in a chaperone. She didn't see how absurd that was until I reversed the picture, recommending bringing in a male chaperone if an adolescent girl was embarrassed.

Most importantly, despite lip service to the contrary, 90% of chaperone use is to protect the doctor and bares no relation to patients' wishes. In all categories, for all exams, most patients are more comfortable with only the doctor being present and don't wish for chaperones.

Anonymous said...

Joel -- one aspect of the denial in this area, is the last statistic estimate you quoted, and the strong probability that chaperones in reality are for the doctor's protection. That's not how it's worded in all chaperone policy statements I've found. Patient comfort is always the first reason for chaperones, patient protection is usually the second reason -- doctor protection is always last.
So -- this is an example of the elephant in the room syndrome. We don't want to talk about, in public, out loud, why chaperones are really used. We say in print one thing, but the real reason is known, but rarely if ever acknowledged in speech or print.
This syndrome is not limited to medicine, of course. We see it in all aspects of our society. But we're discussing medicine here, so we can look to see all these other examples of the elephant in the room syndrome in health care. There are many. And it's connected to the power structure and "secret" culture of medicine that I've talked about in past posts.
More later on the elephant in the room syndrome and why we tend to see things and not acknowledge or talk about them -- and how we're socialized to do this. I'm finding the research in this area fascinating and tying in directly to what we're talking about on this and Bernstein's blog.
MER

Anonymous said...

"We can't use male staff for that, so it's not economical to hire them."

It's not that they CAN'T, it's that they WON'T. But I essentially understand what you're talking about MER and Joel.

S

Anonymous said...

MER, what is the name of the book? Sounds interesting.--rsl

Anonymous said...

To rsl:

There are several books. One of the best is "The Elephant in the Room: Silence and Denial in Everyday life" by Eviatar Zerubavel.
MER

Joel Sherman said...

THIS THREAD IS FULL AND WILL NOT ACCEPT FURTHER POSTS. PLEASE CONTINUE ON PART 2.

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