• Have a chaperone present for all breast, genital, and rectal exams ° irrespective of gender of the examining physician ° in inpatient and outpatient settings ° during labor and delivery ° during diagnostic studies (e.g., transvaginal ultrasonography and urodynamic testing) • Report observed or suspected sexual misconduct to appropriate authorities ° Supervisors ° Department chairs or other institutional authorities ° Peer review organizations ° Professional licensing boards ° Law enforcement, in cases of sexual or physical assault • Create and follow clear guidelines for staff to report without fear of retaliation • Educate students and trainees regarding the inherent power imbalance in the patient- physician relationship, procedures for reporting suspected misconduct, risk factors for sexual misconduct, and need to avoid sexually offensive or denigrating language More on Use of Chaperones Chaperones in the exam room reassure the patient of the professional nature of the exam and intent of the physician, witness all events that take place, and deter potential inappropriate behavior. 13 Guidelines from an ACOG committee now recommend routine use of chaperones for all intimate examinations, which is a change from the organization’s previous “opt-in” approach when mandated by policy or requested by the patient. 13 Exceptions would be in an emergency when a failure to perform the exam would result in significant and imminent harm to the patient or when a patient declines the use of a chaperone. 13 A patient who declines having a chaperone present should be counseled as to the reason a chaperone is integral to providing good medical care and be informed that the policy is to protect both patient and physician. The physician should listen to any concerns of the patient and, if possible, take steps to address the concerns. If the patient still refuses the chaperone, the physician is to respect and document the decision. 13 A physician may elect to defer breast, genital, or rectal exams if they are to be performed unchaperoned. Therefore, patients may opt out of a chaperoned exam, but physicians are not compelled to examine without the protection of chaperone except in cases of medical emergencies. All information regarding chaperones, should be documented in the medical record. The AMA position regarding chaperones is that physicians should ensure: 41 • Patient are free to request a chaperone during any physical exam, and that this policy is communicated to patients • A patient’s request for a chaperone is honored
• A chaperone is an authorized member of the health care team • Chaperones are held to clear expectations of upholding professional standards of privacy and confidentiality of health information • There is general use of chaperones even when a patient’s trusted companion is present • Opportunities occur for private conversation with the patient without the chaperone present • Inquiries or history taking of a sensitive nature is minimized during a chaperoned examination Chaperones should be trained in best clinical practices and empowered to report misconduct through an independent process. 13 Use of trainees, such as medical students or residents, as chaperones is discouraged unless they are similarly trained in best practices and empowered to report any concerns independent of the physician. 13 Family members may be present if requested by patients but are not to be used as chaperones. 13 Staffing should be adequate to protect patient privacy and permit routine use of chaperones. Any failure by a physician to adhere to policy concerning chaperones should be reported to the appropriate manager (e.g., medical director, chief, or chair). Organizations should have channels for anonymous reporting either by phone or by online template. Unfortunately, sexual misconduct can and does occur with a chaperone (or others) present. It is telling that disgraced gymnastics doctor Nassar engaged in sexual misconduct with patients with parents present in the room. 38 Chaperones sometimes look away or engage in doing paperwork out of a mistaken idea that they are respecting patient privacy or implying trust in the process. It is essential that the chaperone be properly trained to observe while maintaining patient privacy, to remain engaged, to recognize inappropriate behavior, and to know how to speak up if sexual misconduct is seen. 6 BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 3 ON THE NEXT PAGE. Respectful Communication/Social Media Use Generational values evolve in terms of what is considered respectful communication. In the past, such values might have manifested in speaking of “romantic relationships” with patients or as fear of putting physicians “out of work” by reporting misconduct. The FSMB report on sexual misconduct states that so-called “romantic” behavior between a physician and a patient would at least constitute grooming and is never appropriate despite any appearance of consent on the part of the patient. 1 There are other examples of generational change. Previous calls to separate personal and professional identities online have been lately criticized as unnecessary or impossible. 42 Some modern physicians are not sticklers for being addressed as “Doctor” rather than by their first names. Guidelines can be expected to change
further along with technology and the larger culture. Yet however culture changes, principles of medical professionalism are still rooted in respectful recognition of boundaries. 43 The goal is to earn and retain the public’s trust. Some best practices in every circumstance include to: 43 • Guard against excessive self-disclosure • Maintain integrity, compassion, and respect for others • Respect patient privacy and autonomy • Maintain accountability to patients, society, and the profession • Be sensitive to diverse populations • Commit to ethical principles regarding care, confidentiality, informed consent, and business practices Lines may become blurred when there is limited access to medical care, including in rural areas where physicians are well-known members of the community. Even so, well-established professional boundaries can help protect physician practices and preserve quality patient care. Suggestions for properly establishing the physician-patient relationship and precluding even the appearance of impropriety include: 44 • Discouraging informal inquiries by insisting patients be seen in-office whenever possible • Engaging in ongoing evaluation of objectivity in treating friends or family members • Realizing when objectivity is compromised regarding any patient and referring immediately to another physician • Redirecting patients who call outside of office hours to the on-call physician or to wait until morning, excepting emergencies • Always charging for services • Examining members of the opposite gender only with a staff person of same gender as the patient in the room • Politely but firmly deflecting any behavior (e.g., hug or kiss on the cheek from a close friend) that may be regarded by staff or others as inappropriate conduct with a patient • Referring intimate partners to another physician • Refraining from intimate partnerships with staff members and patients Communication skills include using social media professionally. Social media is now part of medical education, patient engagement, and quality improvement initiatives 43 and also provides professional opportunities, camaraderie with others in the medical field, and opportunities to disseminate beneficial public health messages. With these privileges come responsibilities and new challenges to the patient-physician relationship. Social media posts are public and can have immense longevity and reach as a result of being shared by others. 43
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