New guidance from ACOG on trained chaperones
The American College of Obstetricians and Gynecologists (ACOG) recently issued a committee opinion recommending “that a chaperone be present for all breast, genital, and rectal examinations. The need for a chaperone is irrespective of the sex or gender of the person performing the examination and applies to examinations performed in the outpatient and inpatient settings, including labor and delivery, as well as during diagnostic studies such as transvaginal ultrasonography and urodynamic testing.”7
This new proscriptive guidance will significantly change practice for the many obstetrician-gynecologists who do not routinely have a chaperone present during intimate examinations. The policy provides exceptions to the presence of a chaperone in cases of medical emergencies and if the patient declines a chaperone. ACOG recommends that when a patient declines a chaperone the clinician should educate the patient that a “chaperone is an integral part of the clinical team whose role includes assisting with the examination and protecting the patient and the physician. Any concerns the patient has regarding the presence of a chaperone should be elicited and addressed if feasible. If, after counseling, the patient refuses the chaperone, this decision should be respected and documented in the medical record.”7 ACOG discourages the use of family members, medical students, and residents as chaperones.
Trauma-informed care
Sexual trauma is common and may cause lasting adverse effects, including poor health.1 When sexual trauma is reported, the experience may not be believed or taken seriously, compounding the injury. Sometimes sexual trauma contributes to risky behaviors including smoking cigarettes, excessive alcohol consumption, drug misuse, and risky sex as a means to cope with the mental distress of the trauma.
Trauma-informed medical care has four pillars:
1. Recognize that many people have experienced significant trauma(s), which adversely impacts their health.
2. Be aware of the signs and symptoms of trauma.
3. Integrate knowledge about trauma into medical encounters.
4. Avoid re-traumatizing the person.
Symptoms of psychological distress caused by past trauma include anxiety, fear, anger, irritability, mood swings, feeling disconnected, numbness, sadness, or hopelessness. Clinical actions that help to reduce distress among trauma survivors include:
• sensitively ask patients to share their traumatic experiences
• empower the patient by explicitly giving her control over all aspects of the examination, indicating that the exam will stop if the patient feels uncomfortable
• explain the steps in the exam and educate about the purpose of each step
• keep the patient’s body covered as much as possible
• use the smallest speculum that permits an adequate exam
• utilize a chaperone to help support the patient.
Clinicians can strengthen their empathic skills by reflecting on how their own personal experiences, traumas, cultural-biases, and gender influence their ap-proach to the care of patients.
Reference
1. Hall KS, Moreau C, Trussell J. Young women’s perceived health and lifetime sexual experience: results from the national survey of family growth. J Sex Med. 2012;9:1382-1391. doi: 10.1111/j.1743-6109.2012.02686.x.
Training of chaperones
Chaperones are health care professionals who should be trained for their specific role. Chaperones need to protect patient privacy and the confidentiality of health information. Chaperones should be trained to recognize the components of a professional intimate examination and to identify variances from standard practice. In many ambulatory practices, medical assistants perform the role of chaperone. The American Association of Medical Assistants (AAMA) offers national certification for medical assistants through an examination developed by the National Board of Medical Examiners. To be eligible for AAMA certification an individual must complete at least two semesters of medical assisting education that includes courses in anatomy, physiology, pharmacology, and relevant mathematics.
Reporting variances that occur during an intimate examination
Best practices are evolving on how to deal with the rare event of a chaperone witnessing a physician perform an intimate examination that is outside of standard professional practice. Chaperones may be reluctant to report a variance because physicians are in a powerful position, and the accuracy of their report will be challenged, threatening the chaperone’s employment. Processes for encouraging all team members to report concerns must be clearly explained to the chaperone and other members of the health care team. Clinicians should be aware that deviations from standard practice will be reported and investigated. Medical practices must develop a reporting system that ensures the reporting individual will be protected from retaliation.
In addition, the chaperone needs to know to whom they should report a variance. In large multispecialty medical practices, chaperones often can report concerns to nursing leaders or human resources. In small ambulatory practices, chaperones may be advised to report concerns about a physician to the practice manager or medical director. Regardless, every practice should have the best process for reporting a concern. In turn, the practice leaders who are responsible for investigating reports of concerning behavior should have a defined process for confidentially interviewing the chaperone, clinician, and patient.
Even when a chaperone is present for intimate examinations, problems can arise if the chaperone is not trained to recognize variances from standard practice or does not have a clear means for reporting variances and when the practice does not have a process for investigating reported variances.
Sadly, misconduct has been documented among priests, ministers, sports coaches, professors, scout masters, and clinicians. Trusted professionals are in positions of power in relation to their clients, patients, and students. Physicians and nurses are held in high esteem and trust by patients. To preserve the trust of the public we must treat all people with dignity and respect their autonomy. The presence of a chaperone during intimate examinations may help us fulfill Hippocrates’ edict, “First, do no harm.” ●
Why patients prefer not to have a chaperone present during their pelvic examination— A clinician’s perspective
Ronee A. Skornik, MSW, MD
As a female obstetrician-gynecologist trained in psychiatric social work, I have found that some of my patients who have known me over a long period of time find the presence of a chaperone not only unnecessary but also uncomfortable both in terms of physical exposure and in what they may want to tell me during the examination. Personally, I strongly favor a chaperone for all intimate examinations, to safeguard both the patient and the clinician. However, I do understand why some patients prefer to see me without the presence of a chaperone, and I want to honor their wishes. If a chaperone is responsive to the patient’s requests, including where the chaperone stands and his or her role during the exam, the reluctant patient may be more willing to have a chaperone. A chaperone who develops a relationship with the patient and honors the patient’s preferences is a valuable member of the care team.