Chaperone Use by Family Physicians During the Collection of a Pap Smear

I appreciate the authors addressing an area that has recently produced an unexpected angst during the routine workday. I initially performed all pap smears and pelvic exam alone, wishing to respect the patients right to privacy. At one clinic, I was informed that all providers should have paps/pelvic exams chaperoned for medico-legal reasons with no further explanation. I complied although I had to wait for a medical assistant to finish giving vaccines, or just remove them from some other task. This was frustrating. One day a patient demanded a pelvic exam. The patient seemed to be under the influence of an illicit substance. I recommended the patient reschedule when she was feeling more "herself." During the history and physical, the patient explained and cried that she had had unprotected sex the night before and would not be happy unless she underwent an exam. The patient declined taking any illicit drugs when I asked for her social history. Despite attempting to explain that the disease might not have manifested itself and that a repeat exam would be necessary in the not so distant future including repeating STD labs, the patient was adamant to have the exam. After she calmed down upon my suggestion, I agreed to perform the exam. She tolerated the procedure well and when she sat up, I asked her a few questions to close the exam. I repeated the drug questions from the social history and the patient lunged at me in the presence of my medical assistant and then proceeded to use very colorful four-letter words before stomping out of the exam room and the office. I reported the incident to the medical director, but I didn't need to, the whole office heard the patient ranting and raving. I was very happy to have a chaperone at that time. I also work in ethnically diverse populations and although initially a patient may be reluctant to have a chaperone, I have found that the more conservative, religious non-English speaking patients feel more relaxed with a medical assistant to "hold their hand" and talk them through the examination. I have heard horror stories from my 80 year old great aunt about obstetricians making inappropriate comments during the pelvic exam and I have heard stories of physician's not wearing gloves during a pelvic exam. I cannot prove the latter tale but it does open Pandora's box. Should we legalize chaperoning pelvic exams for male and female physicians/providers?

Competing interests:   None declared

A very good point. However, the use of chaperone could actually improve the efficiency of office flow if their role was more than just observation. If there is a team approach between the nurse/ medical assistant in the interaction with patient, then the efficiency could improve.

From my observation of hundreds of family practice ofices in the community, most are not efficiently orgnized in terms of the use of office staff. For example, I was consulting to a well established practice of 3 physicians and 2 nurse practitioners. When asking the job descriptions of the nurses and medical assistants, they uniformly responded to keep providers from having a fit at 5 PM on Friday. This type of personnel management to avoid crisis is very common and not unexpected. Medical training does not provide insight into management of practice.

Mack T. Ruffin IV University of Michigan

Competing interests:   None declared

Pertinent topic. Cogent responses.

With overhead rising and reimbursement shrinking, efficiency is paramount if we hope to be able to continue to function as physicians. The routine use of chaperones certainly removes a staff member from more productive activity. And for what?

Do we really believe it reduces patient anxiety or likelihood of the allegation of sexual impropriety?

If such defensive tactics are deemed necessary, then why not during the cardiac exam, what with the exposed breasts, physician's hand-under-patient's shirt, etc.? An ambitious/dishonest litigant could allege that impropriety transpired during a simple ear exam if no chaperone were present. Where do we stop?

Personally, a chaperone during pap/pelvic doesn't strike me as inefficient or awkward since an assistant handing spatula, fixing slide, is clearly helpful. But for breast exam, standing there doing nothing but keeping an eye on that doctor. . .? What a message to send!

Good topic, but perhaps more relevant if "chaperones in general" (beyond the context of pelvic exam) would be more enlightening.

Competing interests:   None declared

This excellent manuscript by Drs. Rockwell, Steyer, and Ruffin evokes the need to research this area in more depth. I would totally agree. Further issues to be investigated might include: 1. Examining young children alone, with parents or a chaperone. 2. What role does a patient’s psychosocial state play in deciding if a chaperone should be utilized (depression, psychosocial dysfunction or previous sexual abuse)? 3. What about female physician performing intimate examinations on adolescent males? 4. Is the sex of the chaperone a significant issue? The authors point out the need to answer many questions that are practical to everyday clinical practice. Studies indicate a majority of women undergoing intimate examinations preferred to be alone when the doctor or nurse is a female.1 On the other hand when the physician is a male most women prefer a chaperone.2 Furthermore the literature on this issue points to differences in preferences of women undergoing pelvic examination in reference to whether this is their first pelvic exam, age at exam and previous experience with a gynecologic examination.3

I disagree with the thrust of the authors final statement," We believe the question with highest priority is, What is the perspective of patients?" Due to the myriad of factors involved in this intimate process the decision whether or not to utilize a chaperone must be equally shared by physician and patient. I feel the physician's decision should be equally weighted. Furthermore, the resolution of this challenging issue could serve to further cement the doctor patient relationship.

1. Khan NS, Kirkman R. Intimate examinations: use of chaperones in community-based family planning clinics. BJOG. 2000 Jan;107(1):130-2. 2. Patton DD, Bodtke S, Horner RD. Patient perceptions of the need for chaperones during pelvic exams. Fam Med. 1990 May-Jun;22(3):215-8. 3. Fiddes P, Scott A, Fletcher J, Glasier A. Attitudes towards pelvic examination and chaperones: a questionnaire survey of patients and providers. Contraception. 2003 Apr;67(4):313-7.

Lawrence I Silverberg, DO

Competing interests:   None declared

Drs. Rockwell, Steyer, and Ruffin ask an excellant question at the close of their article: Do the patients want chaperones? There are many reasons why they might not want another person in the room including but not limited to: belief that the physician does not trust the patient, not wanting the embarrassment of having a possibly less known or unknown person watching, violation of the doctor-patient relationship, privacy issues especially in the light of possible physical findings. We should evaluate what the patients want and probably need to do this not only on a population-level but also individulally in our clinics, as desires may vary from patient to patient.

Physicians may not be willing to give up their chaperones, even when the patient desires to not have any, because of concerns over lawsuits. This is the case for one of the major barriers to patient-centered care: the doctor does not always feel comfortable with allowing the patient to make decisions that may not be the best for the patient's health or for the doctor's malpractice. Knowledge of the actual health effects of the decisions patients make and knowledge of the likelihood of charges of malpractice will help both doctors and patients to jointly decide on the correct course of action.

Competing interests:   None declared