News of physicians accused or convicted of sexually inappropriate behavior toward patients during medical exams has been frequent recently. And patient advocates have brought up the fact that many patients are uncomfortable during sensitive exams.
As a result, more doctors and medical organizations are using chaperones to protect the patient and the physician.
For some institutions, the movement has been toward mandating chaperones. Chaperones can be present for any examination of what are often referred to as sensitive areas, such as breasts, genitalia, and the perianal area. For example, Yale University Health requires patients to use a medical staff member as a chaperone for all sensitive exams except in emergency situations. UCLA Health, on the other hand, allows any adult or child aged 12 years or older to decline a chaperone if they wish to do so. Michigan Medicine provides a chaperone on request, although a patient can opt out.
Many physicians fully support the concept. "If a patient requests a chaperone I think we all, as practitioners, should honor that request respectfully," says Shieva Ghofrany, MD, an ob/gyn practicing in Stamford, Connecticut, and co-founder of tribecalledv, a women's health knowledge platform. "It's a clear sign a patient wants to ensure that they feel safe and comfortable."
However, using a chaperone can be challenging for many primary care physicians and specialists in terms of logistics. Should a chaperone's job be purely observational? Or should the chaperone also be a medical professional who assists during the procedure? How, specifically, should a chaperone perform their duty during an exam? Where should the chaperone stand? What about legal and ethical ramifications? Let's take a closer look at these specific questions and how to make the process both seamless and successful.
Who Should Be a Chaperone?
The role of a chaperone is sometimes vaguely-defined. It's logical that a chaperone should have sufficient medical knowledge. Could it be a medical student? Should it be a nurse or another doctor? Would a patient representative suffice even if they aren't a direct-care clinician?
There are no set standards about who can assume the role. However, the American Medical Association recommends that a patient chaperone be an authorized member of a healthcare team. For many patients, this is vital.
"As a survivor of sexual assault by an ob/gyn while I was pregnant, I can assure you that the heinous crime committed against me and hundreds of other women would have been prevented had there been another medical professional in the room," says Laurie Kanyok, founder of a dance company in New York City, whose former doctor was recently convicted of federal sex abuse charges and is scheduled to be sentenced in July 2023. "The chaperone should be a physician assistant, nurse or medical professional. Qualified professionals better understand the nature and protocols of an exam."
For children and adolescents, allowing a parent to be a chaperone might be a logical and comforting choice. However, a new British study finds that it's not appropriate.
Study authors Rebecca Jane Moon and Justin Huw Davies looked at pubertal staging–related exams and contend that a chaperone should always be impartial, and a parent's presence could conceivably open up a physician to false charges of misconduct.
The solution: A parent should have the option be present during any physical exam of their child, with a medical professional additionally acting as chaperone. This can also work for any patient who wishes to bring a trusted friend or family member to their medical appointments.
How Does a Chaperoned Exam Work?
A research team from the Medical College of Wisconsin and Louisiana State University Health conducted a recent systematic review of patient and clinician perspectives on carrying out a chaperoned urology exam. The review found that the protocol could use improvement. For example, it was reported that over one quarter of patients didn't feel comfortable asking for a chaperone if they were not offered one. "Patients should not have to request this," says Diana Londoño, MD, a board certified urologist and assistant clinical professor at City of Hope National Medical Center in Duarte, California.
The researchers also found that 93% of female patients preferred a chaperone of the same gender, whereas male patients were split on this issue. Key duties of a chaperone should be to ensure privacy, help interpret instructions from doctor to patient, and continually clarify that consent is being requested as a sensitive exam proceeds, the researchers report. Although clinical practice standards for chaperones aren't uniform, keeping these important points in mind can easily be adopted by any healthcare provider.
Many doctors do follow their own set guidelines. "Often, we have our medical assistants be our chaperones," explains Ghofrany. "Ideally they 'room' the patient — take vitals and ask the patient what specific concerns they would like to address. This helps with exam set-up.
"For example, if a patient has a breast concern vs a concern about their genital area, this would change what drapes are used. The medical assistant would then stand near me if they are helping with a Pap smear or cultures, or they may stand by the patient's head at the bedside and offer support if needed. Some patients want to hold someone's hand during an uncomfortable exam."
The issue of positioning is important. A patient may feel very uneasy if it appears that the chaperone is looking at their body from the doctor's angle, negating the point of reassurance. The key is to explain prior to an exam exactly how a chaperone is needed during the exam itself and whether the chaperone is a medical assistant or nurse.
"Chaperones usually stand next to me on either side or on the side of the patient facing me, depending on if they are immediately assisting me or helping the patient," says Londoño. If a chaperone will be moving back and forth during the exam, that should be conveyed as well. For virtual visits, a chaperone can act as a third party and be present on a split screen, a process Michigan Medicine uses.
It's also important to inform patients that a chaperone can step in and stop an exam at any point, both at the patient's request or because of any observation of inappropriate physician behavior. Understanding this can help reluctant patients feel less worry.
When Christian Miller was diagnosed with a sleep disorder, his doctor suggested having a chaperone present during his physical exams. At first, he was apprehensive but then found the experience to be very positive. "Having someone there with me gave me an extra measure of assurance that nothing untoward would happen," he says. "I found that having a chaperone was reassuring. The chaperone was not intrusive but stood close enough to ensure everything went smoothly and respectfully."
Do Chaperones Help Protect Physicians Legally?
Some states mandate that chaperones be present by patient request during sensitive exams, such as Texas and Oregon. For the most part, though, physicians have no legal obligation to offer chaperones, although it could be in their best interest to do so.
Ob/gyn is one of the most litigated specialties, for example, so these physicians may find chaperones can play a key role in averting lawsuits. According to data from Physicians' Insurance, having a reliable witness in an exam room can mitigate claims, and doctors should follow a clear practice policy regarding chaperones for all patients to further reduce liability.
Another advantage to having a chaperone present: protection for a doctor against a problematic patient. The risk for assault or aggression during an exam can of course go both ways. It's important to be able to prove any patient misconduct through a witness, and a chaperone can lessen the prospect of violence in any form. "Having a chaperone in an exam room is about protecting the doctors as well as the patient," says Kanyok.
A chaperone can also defuse ethical dilemmas. Let's say a patient refuses to allow a chaperone in an exam, but it's required by that physician's healthcare organization. Asking a patient to state their reasons for wanting privacy with the chaperone present prior to the actual exam can help document the patient's wish respectfully as well as protect a physician and organization from any potential liability if the patient refuses the exam altogether or if an exception for the patient is made.
Making a Chaperone Policy Work Best
Have your staff inform patients of a medical chaperone policy at the time an appointment is made. Have fact sheets available for the patient prior to appointments fully outlining your policy.
Inform the chaperone fully about the details of the exam and the patient's case prior to the exam, in accordance with HIPAA.
The chaperone can introduce themselves to the patient in the waiting room or exam room before you enter the room. The chaperone can go over the policy again verbally and answer any questions the patient may have initially. You can then clarify whether the patient understands your chaperone policy when you come in.
Document, document, document. Write down who the chaperone was for each exam in patient notes and note the details of any interactions that are significant, such as patient questions or conflicts.
Practice respect, above all. "A patient's safety and level of comfort should be prioritized," says Kanyok.
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Cite this: Chaperones for Physical Exams? Doctors and Patients Weigh In - Medscape - Jul 24, 2023.