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Respecting Patient Autonomy

Patient in gown sitting on examining table with ankles crossed, shown from chest down
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Boundary Violations policy clarifies expectations for examinations

A recently approved policy articulates a new expectation and clarifies several others for the purpose of ensuring the dignity, privacy and autonomy of patients during examinations.

Although, most physicians are mindful of the importance of approaching examinations in a sensitive, thoughtful manner, the College does continue to receive complaints from patients who have concerns about boundary issues.

The Boundary Violations policy was developed to help physicians understand and comply with the legislative provisions of the Regulated Health Professions Act, 1991 regarding sexual abuse. It also sets out the College’s expectations for physicians related to establishing and maintaining appropriate boundaries with patients, including both sexual and non-sexual boundaries.

Below are some of the policy’s expectations as it pertains to conducting examinations.

Obtaining Consent Before Proceeding with Examination

The policy requires physicians to obtain consent before proceeding with an examination of a patient. But the process does not have to be onerous or time-consuming and can simply include a concise explanation of what the exam will entail in order to promote patient understanding, states the policy’s accompanying Advice to the Profession document.

Prior to examining your patient, explain what you will be doing and why in a concise and easily understood manner. Then you can ask, “is this okay?” In this way, the patient will know what to expect during the examination.

Prior to examining your patient, explain what you will be doing and why in a concise and easily understood manner.

Privacy

We have added more detail about the importance of privacy in this policy. The policy requires physicians to provide privacy when a patient undresses and dresses. This can be achieved by having an appropriate place for a patient to undress and dress out of view of anyone, including the physician. This could be a separate examination room where a patient can change or having a suitable curtain between the physician and the patient. Merely turning around and facing away from a patient without a curtain is not acceptable.

Third Party Option

The policy clarifies that physicians must give patients the option of having a third party present during an intimate examination. This expectation applies regardless of the gender of the physician and/or the patient.

If a physician is unable to offer a third party, it is suggested that, in the course of booking an appointment, that the patient be invited to bring their own third party – a friend or a family member, if they so wish.

If the patient wants a third party present during an intimate examination, and a third party is unavailable or there is no agreement on who the third party should be, physicians must:

A. Give patients the option to delay or reschedule the examination or be referred to another physician if the examination is not urgently needed, or
B. Explain the risks of delaying the examination if the examination is urgently needed.

Physicians also have the option to request the presence of a third party during an intimate examination. If doing so, a physician must explain to the patient who the third party is. If the patient declines, physicians must consider whether to proceed with the examination based on the best interests of the patient, including whether or not the examination is urgently required.

In limited clinical settings, an intimate examination may not be as foreseeable as it would in a different setting (e.g., a scheduled pelvic examination) and it may be more difficult to find an available third party. In these circumstances, where the patient does not have an available third party who has accompanied them, a physician could explain to the patient that a third party may be obtained but it could take some time for this to happen. If the examination is not urgent, the patient can then decide whether they want to wait until the third party can attend. In terms of documentation, it may be worthwhile for a physician to document when a patient declines the third party option. If a third party is present, physicians may want to document whether the third party has been provided by the physician or the patient.

For information, please read the article about the policy’s expectations on dual relationships.