Conducting Sensitive Exams
Communication key to ensuring patient feels sense of control
In the course of any given day, a doctor may perform a number of intimate examinations. But receiving an intimate exam is anything but routine for patients and most people experience trepidation at the prospect.
Recently, we spoke to Dr. Anil Chopra, CPSO’s newest medical advisor and the former chair of the Inquiries, Complaints and Reports Committee (ICRC), about the best practices in conducting intimate examinations with sensitivity and respect.
What are some of common themes arising from patient complaints about intimate exams?
The most common issues are related to communication, privacy, including draping, and the patient experience. If the physician did not take the time to adequately explain to the patient the examination that was about to take place, how it was going to be conducted and why it was necessary, it could result in a poor patient experience. Without this proactive communication, the patient may feel violated and have concerns about inappropriate touching by the physician.
As a physician prepares to perform an intimate exam, what needs to be uppermost in the physician’s mind in regard to the patient experience?
To ensure that the examination can be conducted in a place with appropriate privacy, allowing the patient to disrobe and dress as required with available gowns and sheets to maintain modesty and keep the patient comfortable. The physician, generally, should not assist the patient to undress (unless the patient requires and requests assistance), and should leave the patient’s room or use curtains and screens to allow the patient to undress and gown up privately. The physician should also always use gloves when examining the pelvis, genitals and perianal area. And physicians should avoid any unnecessary touching which is not medically indicated.
Can you describe the communication necessary before and during an exam?
An essential part of the communication is consent. Before any examination is initiated, whether intimate or not, the patient must understand what examination is being proposed, why it is being proposed and provide consent to allow the physician to proceed. It should be made clear to the patient that they always maintain the right to refuse, defer or stop an examination already underway. Secondly, in the case of intimate exams, it should be standard practice for a physician to inquire about whether the patient wishes to have a third-party present in the room. And as you are conducting the exam, a patient can feel more in control of what is happening if you provide a commentary about what you are doing and any adjustments you are making to the examination.
Would it be accurate to say the more invasive the exam, the more explicit the communication needs to be?
Yes, the more invasive the examination, the greater the need to ensure the patient understands the procedure, any associated and anticipated discomfort, and has the ability to slow or stop the procedure at any time. The physician needs to create a safe space for these invasive examinations and allow the patient the time to ask questions if they arise before the examination begins. Furthermore, the physician should watch for verbal and nonverbal cues by the patient to adjust the examination accordingly.
If a patient remains silent, can you assume the patient is okay with the exam?
No. A patient may be silent because they don’t understand what is being proposed or are hesitant to ask questions. It is always good practice to use open-ended questions before the examination begins, such as “Any questions or concerns?” and specific consent to proceed, such as “Should we proceed with the exam?”
Can you describe what a physician’s explanation gives a patient?
It gives a patient an understanding of why the examination is necessary and how it will be performed and, significantly, it gives them a sense of control over what is happening. The explanation also allows the patient the opportunity to ask questions and provide consent.
Some physicians may feel that communicating with patients on different aspects of their exam is onerous and time-consuming. Could you please address that concern?
The same principles apply for new and existing patients, but as there is no pre-existing relationship with new patients, extra care and communication is needed to build the relationship and trust. Physicians should be extremely careful not to make assumptions with new patients and taking a trauma-informed approach with all new patients would be best practice. Though it certainly takes extra time to properly communicate with a patient about an examination, it will create a better patient experience and likely prevent any misunderstanding which could lead to a patient complaint. A physician should always allocate enough time during a patient visit so that there is sufficient dialogue for the patient to understand what is about to occur and consent to it.
In the case of a pelvic examination, should the headrest on the examination table be angled so the patient can see the physician throughout the exam?
It is always good practice to maintain eye contact with the patient during the examination whenever possible as the patient may feel less vulnerable this way.
Our Boundary Violations policy requires patients be given the option of having a third-party present. Do you have any insights as how to make that inclusion as seamless as possible?
As an emergency physician, I have a third-party present (usually a nurse) for all intimate examinations in the emergency department. In the clinic situation, offering the patient the option of having a third-party present during an intimate examination is always important, irrespective of the gender of the patient. The approach may differ depending on whether the physician/patient relationship is new or episodic versus a long-standing relationship, but incorporating the inquiry as a standard question before every intimate examination ensures that the patient always has the opportunity to request one. Physicians should be aware that if the patient requests a third party’s presence, but one is not immediately available, the patient should be given the choice to delay or defer the examination if the examination is not urgently needed. Documenting the patient preference and whether a third party was present during the intimate examination is good practice.
What can be done to maintain patient privacy while the patient disrobes/dresses?
If the patient is in a single patient room, then the physician should leave the room to allow the patient to undress and gown up. If that is not possible, the patient should be shielded with curtains or screens, which allow for appropriate privacy. Measures should be taken to confirm the curtains and screens are not torn, fail to close properly or inadequately block visibility.