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Friday, January 23, 2015

Do Female Physicians Need Female Chaperones?

Genmedmom here.

Our department is considering a policy that would require female chaperones to monitor every pelvic exam. This would include pelvic exams performed by female providers.

As a primary care women's health doc who performs pelvic exams every day, I felt vaguely insulted by this.

But, as both a female physician as well as patient, I understand the reasoning behind this potential policy. In our department's case, it was apparently proposed in response to a complaint involving a female physician; we have no idea what the issue was. Of course, historically there have been cases where there was abuse of the doctor/ patient relationship in this context. Also, cases of perceived abuse. To have an official "observer" present can help to prevent any abuse, or false claims.

My own OB/GYN office uses chaperones. But it always strikes me as odd and impractical. My own OB/GYN is an excellent physician with superior bedside manner who has overseen both of my pregnancies; she even guided me safely through a VBAC. But even she has to leave the exam room and go fetch a medical assistant, who may have never met me and is not involved with my case, so that they can stand there and observe what is basic, routine office care. I've considered requesting that she NOT go fetch the superfluous eyeballs, as I think it's kind of weird, and it would save time, too. But I haven't wanted to rock the boat.

So, as I have myself experienced, having an additional person present for this exam can also in and of itself be uncomfortable, and can make routine medical care feel weird. It may not help many women to feel more comfortable at all.

Are there things we providers can incorporate into practice that can help minimize discomfort and prevent abuse, or perceived abuse?

I really try to help patients through what is generally considered, at the very least, an uncomfortable and awkward examination. For many women, a pelvic exam can even be a traumatic experience, either physically due to atrophy or inflammation, or psychologically due to past rape or sexual abuse.

I think there's some basic things that we can do to help women feel more comfortable and in control when a pelvic exam is necessary. These include explaining why we are doing the exam and what we are looking for before we even start. Does she need a Pap smear, or STD screening, or both? Is she complaining of pain during sex, abnormal discharge, abnormal bleeding? Is there a strong family history of GYN cancers? Is there a family or personal history of melanoma? Then we'll discuss whether the exam will include a speculum exam, or a bimanual exam, or just an external exam, and why. Not everyone always have to do have all of these.

It's important that the patient knows what's going on at all times. I think it's better if the back of the exam table is slightly elevated and the paper drape is pushed down, so that the patient can easily see the provider. I also try to explain everything I'm doing in real time. I don't even touch the patient in that area at all, without saying what I'm doing and why immediately beforehand. I'll hold the plastic speculum up, and explain that it's the same diameter as most regular tampons, that we use plenty of lubrication with this, and it's usually cold. I tend to talk through the entire procedure, Rachel Ray-esque. Often I'll suggest yoga breathing, letting the pelvic muscles and buttocks relax.

In some cases, urinary incontinence is a problem. If Kegel exercises may help, I ask women if they know how to do these. Then, I either test their Kegel, or ask if they want to learn this. What I've seen is that many women who think they're doing a good Kegel squeeze will actually be tightening their buttocks, or simply tilting the pelvis. So I add pelvic floor physical therapy here: a lesson in isolating the pelvic floor muscles, and a test to see if the patient is able to do a decent Kegel. I think if someone walked in as I'm saying "Squeeze!" they'd wonder what was going on. But since Kegel exercises are effective for preventing and treating urinary incontinence, we'd better make sure patients can do them before we recommend them.

Sometimes, a patient is extremely uncomfortable with some part of the pelvic exam. Then, the exam must be halted. I usually pull the drape back down and discuss, ask if they would like to try again, or hold off. I really don't think a provider can proceed in those cases without a time-out and discussion. It's okay, and sometimes absolutely necessary, to just skip the exam. It can be rescheduled; special arrangements can be made as well, as in cases of extreme physical or psychological discomfort, such as exam under anesthesia.

I've had patients tell me that the pelvic exam "really wasn't that bad", or even that they learned something useful. I take this as positive feedback! I'm sure I can do better; we all can. I'd be interested to know what techniques other providers have found to be useful.

If we are required to institute this female-chaperone-for-pelvic-exams policy, it would mean significant logistical hassle. In our office, we work one-on-one with the medical assistants, and several are male. Would the guys need to be let go, transferred to other practices? In addition, our medical assistants perform the phlebotomies on the patients they've checked in. Were this policy to be put in place, we would need to reorganize our whole system, and likely need to adjust the operating budget to include additional staff. And, of course, if we're required to go fetch a chaperone before every pelvic exam, that will add time to all of those patient visits. Either we'll all run even more behind, or we'll have to restructure our scheduling, and likely need to institute longer days for us and our staff, to accommodate. Again, this could mean a budget problem.

In summary, I don't think that requiring a chaperone to stand there and observe every single pelvic exam is a good idea.
But, I'm very curious what women physicians think about this, both as providers and as patients.

What better place to ask, then the physician-mom blog? What's the vote: Yay or nay?

For those docs that perform pelvic exams, what have you incorporated into your practice to help women feel more comfortable and in control?

-Genmedmom

12 comments:

  1. I prefer no chaperone because I think that extra person gets in the way of the relationship between the dr and the patient. We have so little time with the dr these days, everything counts! I prefer no med student for the same reason, though I'm sure I'm not supposed to say that out loud.

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  2. I really hate having a chaperone. My family doc is male, so every time I needed a pelvic he brought in a chaperone, and I hate it -- I don't feel embarrassed or uncomfortable having a necessary pelvic, because I know my doc is concentrating on the exam. I feel super uncomfortable being naked in front of a stranger, who's just standing there watching, especially because, I hate to say it, but I've worked with a lot of MAs and they aren't the most professional people in the world.

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  3. My personal (nonmedical) opinion is that a chaperone should be available upon request, and automatic in special cases such as rape trauma or when working with minors, but it shouldn't be the default.

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  4. As a Pediatrician I always have a chaperone - for smaller children the parents, for adolescents a same sex parent or a Nurse/ Medical Assistant. When I'm at the doctor I've never had one as an adult except when I saw a male surgeon for a hernia - he was one of my Attendings and he always used a chaperone (I was it when I was shadowing him)

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  5. I'm a man and an ER doc. Feel free to discount my opinion for either or both of those reasons.

    I'm firmly pro-chaperone. It protects the physician. Some patients are crazy. Not a little bit crazy, REALLY crazy. And they will lie and make wild accusations. That is why the chaperone is there. I use a chaperone for ALL "bathing suit" exams -- every rectal, every pelvic, every exam of breasts or testicles, every time.

    Now, you are not ER folks and know your patients well, so this is less of a problem. Still, every patient panel has a few whack jobs. If you don't, tell me where you live and I'll move there.

    Most patients don't need a chaperone, but it's like carding people at a bar -- better to card everyone, so there's no argument over who gets carded. We could probably identify with greater than 90% accuracy who represents a possible false allegation. But there is just no diplomatic way to say "Excuse me, but it's my policy never to be alone during these exams with people like you."

    So everyone gets a chaperone. It ain't perfect, but I sleep better.

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  6. Chaperones make me very uncomfortable, to the point that if a physician insisted upon a chaperone, I'd leave and find a new physician. If it were the practice policy, I'd find a new practice.

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  7. If a patient demanded a genital exam with no chaperone present, I would probably require two chaperones to be comfortable. Maybe three.

    But that's just me.

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    Replies
    1. If you're responding to my comment, note I wouldn't demand anything, other than to leave.

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  8. I love the debate here! I definitely see the pros and cons- to TheTracker, I completely see your POV, coming from the emergency room. I never considered that chaperones may be used for perianal/ rectal exams, or for every male genital exam. I shudder to think of the resource allocation issues such requirements would cause our office... But I se your point about all being equal. Emotionally and logistically, I agree with HealthyMom, who prefers chaperones upon request or for certain patient populations.

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  9. I had an MA assisting me with pelvic exams at my last practice before leaving primary care - that was necessary because the rooms weren't set up for gyn exams and I couldn't reach the Mayo table (they REALLY weren't set up right). I worked with a great MA who developed excellent relationships with my patients, so it wasn't a problem. Before that I didn't regularly use a chaperone for anything. I always figured that was one of the benefits of being a woman providing care for women. Never thought about chaperones for testicular exams or hernia checks. Hmm.

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  10. I generally don't have a chaperone with me, being a female, but I have strongly considered it and generally offer if I don't know a patient well or if it's a male I'm examining. For any childhood exam I insist on a parent being present. It's a good call to insist on a chaperone in the Ed though, I think I'll inplement that!

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  11. I am a male and I see a female doctor. She uses a female chaperone. It make me feel very stressed and agitated. I request during the intimate exam a separate gown, that I hold up so that the chaperone does not get any view of my penis or testicles while the doctor is doing the exam, and I try to position my self so that the female chaperone doesn't get a full view of my rectal area. Given that, if I had a choice to have a "male chaperone" I would choose male. I feel there is such a double standard in the medical field. While it is perfectly accepted in the medical field for a man to undergo intimate procedures under the eyes of 2 females in the room, most woman scorn against the idea for their own exams with 2 men in the room. I say what is good for the goose is good for the gander. I am not saying that a woman cannot examine me; I see a female doctor, but what I am advocating for is the "Choice" to have same gender chaperone if I want. I don't want to hear the excuse of cost of having a male nurse available. The exam is about the patient, and how comfortable they feel in the exam room and the doctor practices should really make note of that. I also feel that if a male undergoes special training to become a nurse, he should not be held back from working in a female area such as a breast testing center. A Nurse is a nurse, and it is about time the double standard issue stops.

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