The issue of chaperone use during gynecologic examinations is unsettled. It is not always clear to physicians if and when they should use chaperones. A combination of legal, ethical, and economic pressures influence clinicians' choices. State medical boards can provide direction to physicians on clinical practices that have legal and ethical implications. The objective of this study was to examine current attitudes and policies of United States medical and osteopathic boards related to chaperone use.
Materials and Methods
We mailed a survey and cover letter describing our study to 67 United States medical and osteopathic boards identified by the Federation of State Medical Boards. The letter requested information on chaperone use during gynecologic examinations. We defined the term “chaperone” as someone in the room other than the physician and the patient. The survey requested information about whether the state board had an opinion, position statement, or policy on chaperone use. Copies of any documentation were requested. Information on state laws governing chaperone use and any disciplinary actions or lawsuits directly related to the presence or absence of chaperones was also requested.
Executives at 67 sites were mailed surveys in late November 1997. We received 49 responses and sent a second mailing to the remaining 18 sites in late January 1998. Another nine sites responded and the remainder were telephoned or E-mailed, of which three responded by telephone. Six sites did not respond.
The definitions used to categorize the responses were opinion, the board simply reports having an opinion on chaperone use, but not a published formal position or policy; position, the board has published recommendations or guidelines on chaperone use; and policy, the board issued a directive on chaperone use, and used the term policy in their published statement.
Sixty-one (91%) of 67 boards responded. Fourteen sites (23%) (Arizona [osteopathic], Arkansas, Colorado, District of Columbia, Iowa, Kansas, Maine [medical], Massachusetts, Minnesota, Mississippi, North Carolina, Oklahoma [osteopathic], Tennessee [medical], West Virginia [medical]) reported having informal or unpublished opinions recommending chaperones. Some examples included statements such as “recommends, but only in board minutes,” “opinion not in writing but the board has consistently voiced this opinion (to recommend),” “no written document at this time—caution is urged.” Eleven sites (18%) (California [medical], Georgia, Idaho, Kentucky, Maryland, New York, Ohio, Rhode Island, Virginia, Wisconsin, Wyoming) reported having positions on chaperones that were published, usually by newsletter, for their physicians. Four sites (6.5%) (Alabama, Louisiana, New Jersey, Washington [medical]) reported having policies specifically related to chaperone use. In total, 29 of 61 (47.5%) medical and osteopathic boards indicated having opinions, policies, or positions on use of chaperones. Thirty-two sites (52.5%) reported they did not have opinions, positions, or policies on chaperones. No site reported state laws governing chaperone use. No board replied affirmatively to whether lawsuits or disciplinary actions had been directly related to presence or absence of chaperones. Some boards required physicians who had been disciplined for sexual misconduct to use chaperones as a precautionary measure and a condition of continued medical practice.
Physicians often question whether chaperones should be used and under what circumstances. There is a sparse collection of articles that address chaperone use. A few studies have explored patient preference and physician practice of chaperone use during pelvic, breast, and rectal examinations. A summary of existing studies indicated that many women do not feel strongly about whether a chaperone is present during a pelvic examination.1,2 Those who did want chaperones were more likely to be young, never married, childless, and black.3 One study found that physicians tend to underestimate teenagers' desires for chaperones, type of chaperones (parent versus medical staff), and gender of chaperones (ie, opposite-sex chaperones were undesirable).4 Studies in which physicians were surveyed found that male physicians in primary care practice use chaperones routinely, but among female physicians it was less common.5,6 One study showed that one third of male physicians do not use chaperones during examinations of female adolescents.7 Gabbard and Nadelson8 suggested that chaperone use is always good clinical practice, and strongly recommended chaperones when the patient has a history of sexual abuse, has extreme anxiety or a psychiatric disorder, is litigious, is having a pelvic examination, and when the patient's behavior raises concerns in the physician.
During a physical examination, a physician must best provide a safe environment for the patient. Medical practices are required to provide physically safe environments for patients, but little thought is given to psychological or emotional safety. Presence or absence of a chaperone might increase or decrease patient comfort. The presence of a chaperone is likely to increase safety for patients and physicians. From the physician's perspective, if a patient alleges inappropriate behavior, the chaperone can serve as a witness. From the patient's standpoint, sexual exploitation during an examination is less likely with chaperones.
Several factors can influence physicians' practices of physical examinations. One is the practice or policy used in the program where the physician trained. Other sources of guidance that can influence chaperone use are textbooks of physical diagnosis and obstetrics and gynecology. Barbara Bates' text does not mention the use of chaperones at all.9 Willms, Schneiderman, and Algranati10 state that “[t]he decision to have a third party (chaperone) present for this portion of the examination depends on the clinical setting, the preference of the patient, and the needs of the examiner…. In some circumstances, it is prudent to have a chaperone present for the legal protection of the examiner.” The text by Prior, Silberstein, and Stang11 states: “With a male physician a female nurse in attendance may furnish much comfort and assurance to the patient, and her presence may be important for the legal protection of the male physician…. It is absolutely essential to have a nurse in attendance during the pelvic examination of a psychotic patient or as a witness in the examination of a patient involved in an alleged criminal act. It should be borne in mind, however, that most female patients would rather not have a third person in attendance during the examination.” Novak's Textbook of Gynecology12 suggests that the patient be allowed to “decide whether or not she will be accompanied during the initial examination by spouse, family member, or friend.” Another obstetrics and gynecology text states, “An assistant should usually be present for the pelvic examination to assist in the preparation of specimens and act as a chaperone.”13
Another source of guidance for physicians is professional medical societies. Published standards or guidelines greatly influence the practices of member physicians. Three professional medical organizations have offered guidance on chaperone use. The Council on Ethical and Judicial Affairs (CEJA) of the American Medical Association recently adopted specific chaperone guidelines (Report 10-A-98). The CEJA recommended having chaperones available consistently for examinations. Patients should be made aware of the availability of chaperones, and have the opportunity to request one. They also recommended that a health professional serve as the chaperone (as opposed to a family member or friend). The CETA also suggested providing an opportunity for private physician-patient conversation separate from the examination during which a chaperone was present.
The American Academy of Pediatrics (AAP) Committee on Practice and Ambulatory Medicine has published suggestions to pediatricians on chaperone use,14 which state that “[i]n some cases, either the patient, the parent, the pediatrician, or some combination of these persons may wish to have a chaperone present.” The AAP suggests that in those cases, a chaperone can protect the interests of patients and pediatricians. The AAP further states that “[p]hysician judgment and discretion must be paramount in evaluating the needs for a chaperone; however, the highest priority should be given to the requests of the patient and the parent.” ACOG has published a Committee Opinion that includes guidance about chaperones (ACOG Committee Opinion, Committee on Ethics. Sexual misconduct in the practice of obstetrics and gynecology: Ethical considerations. 1994; No. 144), which states, “The request by either a patient or a physician to have a chaperon[e] present during a physical examination should be accommodated irrespective of the physician's gender.” ACOG also states that the presence of a chaperone can offer benefits for patients and physicians.
Our results show that some state medical boards also give guidance on chaperone use. Although no state board absolutely requires the presence of a chaperone for physical or pelvic examinations, some have developed policies using relatively strong language, eg, “A physician should have a chaperone present.” Four state boards (Kentucky, Louisiana, Rhode Island, and Virginia) have adopted the position developed by the Ohio State Medical Board (Position Paper: Physical Examination by Physicians. March 8, 1989), which states, “A third party should be readily available at all times during the physical examination and it is suggested that the third party be actually present when the physician performs an examination of the sexual and reproductive organs and rectum. It is incumbent upon the physician to inform the patient of the option to have a third party present. This precaution is essential regardless of physician/patient gender.”
Because of the sensitive nature of the examination, the lack of uniformity of available guidance regarding chaperone use, the prevalence of sexual misconduct cases,15,16 and the desire to have an optimal examination for all involved, it is important to give physicians direction on this issue.
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