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Authors, Case History

Charlene Dewey, MD, MEd
Professor of Medical Education, Professor of Medicine and Public Health
Department of Medicine
Vanderbilt University Medical School/Vanderbilt University Medical Center
Nashville, TN

Paula Katz
Associate
Center for Ethics and Professionalism
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Philadelphia, Pennsylvania

Authors, Commentary

Charlene Dewey, MD, MEd

Lois Snyder Sulmasy, JD
Director
Center for Ethics and Professionalism
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Philadelphia, Pennsylvania

Editor

Lois Snyder Sulmasy, JD
Director
Center for Ethics and Professionalism
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Philadelphia, Pennsylvania

Ethics case studies are developed by the �ܼ�����ˮ��̳ Ethics, Professionalism and Human Rights Committee and the ACP Center for Ethics and Professionalism. The series uses hypothetical examples to elaborate on controversial or subtle aspects of issues in the College's Ethics Manual or other College position statements. The current edition of the ACP Ethics Manual and additional case studies and College policy on ethics, professionalism, and human rights issues are available at /clinical-information/ethics-and-professionalism or by contacting the Center for Ethics and Professionalism at 215-351-2839.

Case History

Dr. Smith, a 54-year-old male physician, is seeing long-time patient Ms. Jones, 55 years old, for her annual physical. She arrives with her young adult daughter who is in the waiting room. Ms. Jones is very distraught, telling Dr. Smith she has concerns about a new vaginal discharge.  She asks that it be checked out before moving on to the general exam. Dr. Smith says he will ask for a chaperone, but Ms. Jones immediately responds she’s not comfortable having a chaperone and that she doesn’t want anyone else to know about her concerns, even her daughter. She has been divorced for 2 years and recently met someone online; they were intimate within the last 2 weeks. Before Dr. Smith can respond, Ms. Jones grabs a gown and begins to remove her clothes.

Dr. Smith is taken aback. He contemplates next steps, recognizing the implications for his relationship with his patient and also the potential impact on the full schedule of patients for the day. He immediately asks Ms. Jones, who is still upset, to stop disrobing as he considers what to do and say next. Dr. Smith wonders what takes precedence—Ms. Jones’s wishes which seem to center on confidentiality concerns or maintaining boundaries with a patient, with whom he has a longstanding relationship?

Commentary

Introduction

Dr. Smith was expecting a routine visit today with a patient who has been in his care for many years.  Several questions are on his mind as he contemplates how to respond to Ms. Jones.  Should he leave the room as she changes into a gown and just proceed and document that she refused a chaperone?  Could Ms. Jones’s daughter act as a chaperone?  It seems this situation could easily lead to misunderstandings.  Is he at risk of sexual misconduct allegations?  How should he discuss the issue with Ms. Jones?

Medicine is about relationships. This case demonstrates an important juncture in a patient-physician relationship and emphasizes privacy, confidentiality, clear communications, and the prevention of professional boundary violations.

Dr. Smith and Ms. Jones have a long-term relationship, each with expectations for the relationship.  Ms. Jones is very concerned with privacy, especially around this new health concern. She may expect some bending of the rules about chaperones. Dr. Smith is concerned about his patient’s new health condition, her privacy and confidentiality issues, but also misunderstandings if a chaperone is not present, and with clinic time, flow, and not inconveniencing other patients with appointments.  The dynamic at play forces reflection on how to balance concerns, respect patient privacy, and manage patient preferences and expectations in any—but especially long-term—relationships. How and when is it appropriate to emphasize the role of professional boundaries over patient expectations and wishes? What rules, laws, and ethical standards apply?

Upholding the Patient-Physician Relationship

From Imhotep to Sir William Osler, and from the Hippocratic Oath to the first modern medical practice act, physicians as individuals who care for the sick have promulgated codes and guidelines for practice to serve and protect patients and physician relationships with them.  Society has granted the privilege of self-regulation to the profession with the expectation that the physician will act in the best interest of the patient, and also oversees the practice of medicine through law and regulation (1).   Practice, professional, and ethical guidelines can protect the patient and the physician, as well as the patient-physician relationship. Good patient-physician relationships are built on solid boundaries.

Boundaries, Chaperones, and Major Ethical Considerations in the Patient-Physician Relationship

Professional boundaries and communication about them are critical to the patient-physician relationship. But many physicians may not have been taught ‘how to’ methods for implementing strong professional boundaries in practice or had their performance clearly assessed.

The �ܼ�����ˮ��̳ (ACP) Ethics Manual provides guidance on boundaries and the use of chaperones in the practice of medicine, stating: “In general, the more intimate the examination, the more the physician is encouraged to offer the presence of a chaperone. Discussion of confidential patient information must be kept to a minimum during chaperoned examinations. Family members of the patient should not act as chaperones” (1). The standard also supports effective communication with the patient and/or family on the importance of such boundaries and institutional or legal requirements on the use of chaperones. Because of the sensitive nature of Ms. Jones’s condition, she may see an additional person’s presence during the exam as intrusive and a violation of privacy (1).

The ACP Ethics Manual also notes that “the patient-physician relationship entails special obligations for the physician to serve the patient’s interest” because the physician has specialized knowledge, the relationship is confidential, and illness can bring with it vulnerability for the patient leading to “an imbalance of expertise and power” (1). The American Medical Association (AMA) also supports this noting, “Efforts to provide a comfortable and considerate atmosphere for the patient and the physician are part of respecting patients’ dignity… Having chaperones present can also help prevent misunderstandings between patient and physician” (2), including those of a sexual nature. Both highlight the importance of a safe and professional relationship between doctor and patient.  Likewise, the Federation of State Medical Board (FSMB) recognizes these aspects of the relationship in its report on physician sexual misconduct, noting the physician is always held to the highest level of professional accountability (3).

Sexual misconduct in medicine is a serious violation of patient trust and the patient-physician relationship (4,5,6,7,8).  It also threatens the culture of safety and must be reported.   It can result in physician sanctioning by medical boards, up to and including license revocation, as well as civil liability or criminal prosecution. Physicians should implement strong professional boundaries, including those related to potential sexual boundary violations or misconduct.

The use of chaperones can reduce misunderstandings and the potential for sexual misconduct events and protects both the patient and the physician.   Chaperones may be indicated even for difficult conversations or non-sensitive exams.  Military practice guidelines state that physicians have the right to request the presence of a chaperone for any patient-physician interaction (8).

The American College of Obstetricians and Gynecologists (ACOG) (9) strongly supports the use of chaperones, recommending that “a chaperone be present for all breast, genital, and rectal examinations... Exceptions should be made in circumstances in which it is likely that failure to examine the patient would result in significant and imminent harm to the patient, such as during a medical emergency.”  ACOG continues, “If a patient declines a chaperone, it should be explained that the 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” (9).  If a patient declines a chaperone after counseling, a waiver/documentation should be obtained and placed in the medical record before the exam proceeds. 

Best Practices

No two situations are the same and here, one important fact is this is a long-term patient, not a new one.  How physicians set boundaries and communicate these boundaries are essential pieces of the relationship with any patient. Use of chaperones when appropriate and for any sensitive physical examination or procedure generally should be standard practice. But recognizing patient concerns and feelings are also a big part of the equation.

1. It would be appropriate for Dr. Smith to ask Ms. Jones to wait for a chaperone and to emphasize clinical and professional practice guidelines to her as his reasoning. In some situations, having a patient’s family member if desired by the patient and in conjunction with a staff chaperone could support the patient. The patient’s family member is not the chaperone, but having a patient’s family member present if requested along with the staff chaperone may feel more comfortable for some patients.

2. In a long-standing relationship between doctor and patient, there is often more mutual understanding.  But boundaries can blur. Ms. Jones’s fear may drive her to be more assertive, or even to violate the boundaries of the patient-physician relationship she values. If Dr. Smith can see this dynamic and effectively communicate that boundaries protect both him and Ms. Jones, he could directly address her concerns through empathy and communication. Ms. Jones may then feel more comfortable knowing that the chaperone is not there to listen to discussions or her diagnosis. Dr. Smith can also emphasize the chaperone is a trained office staff and will leave immediately after the sensitive exam is over. Communicating this may support confidentiality and reduce fear for the patient.

3. Failing to use a chaperone during a sensitive examination can put Dr. Smith at risk of misunderstandings or even a sexual misconduct allegation by the patient or a family member.

4. Communication with Ms. Jones is vital.  Although it could prolong the visit, it is critical for the maintenance of professional standards and the patient-physician relationship.  Physicians should always start from a place of listening, including what the patient says and does not say. For Ms. Jones, it may be fear, embarrassment, self-doubt, or other feelings that are at work. With empathy, Dr. Smith might assure her that their long-term relationship won’t change. He might also cite the medical and practice standards to help her understand the need for a chaperone, supporting a stronger patient-physician relationship and informed decision-making. 

As the Manual advises, the need for a chaperone increases with the sensitivity of the exam.  If Dr. Smith decides to examine Ms. Jones without a chaperone, he should clearly document the reasons he gave her for recommending one be present, the patient’s refusal and his rationale for departing from usual practice in the patient’s circumstances. 

Conclusion

Relationships are central to the practice of medicine. Physicians can foster understanding and safe relationships early and continuously by maintaining boundaries. Ethical guidance, professional standards, and clinical practice guidelines support safe patient care. Physicians should deliver patient-centered care respecting patient preferences based on ethical guidance, following laws and regulations that protect their patients and themselves.  Physicians can and should seek the advice of key individuals, organizations, and guidelines for any challenging ethical situations. Ultimately, implementing these boundaries and practices will help to protect patients, physicians, and practice environments.

References:

1. Sulmasy LS, Bledsoe TA; for the ACP Ethics, Professionalism and Human Rights Committee. �ܼ�����ˮ��̳ ethics manual: seventh edition. Ann Intern Med. 2019;170:S1-S32.  .
2. AMA Code of Ethics.  Use of Chaperones.  Opinion 1.2.4.  Accessed at  on 17 July 2024.
3. Federation of State Medical Boards.  Physician sexual misconduct: report and recommendations of the FSMB Workgroup on Physician Sexual Misconduct. May 2020.   Accessed on 17 July 2024.
4. Spickard WA Jr, Swiggart WH, Manley GT, et al.  A continuing medical education approach to improve sexual boundaries of physicians. Bull Menninger Clin. 2008;72:38-53.
5. DuBois JM, Anderson EE, Chibnall JT, et al. Serious ethical violations in medicine: a statistical and ethical analysis of 280 cases in the United States from 2008-2016. Am J Bioeth. 2019;19:16-34.
6. DuBois JM, Anderson EE, Chibnall JT, et al. Preventing egregious ethical violations in medical practice: evidence-informed recommendations from a multidisciplinary working group. J Med Reg. 2018;104:23-31.
7. Cooper WO, Foster JJ, Hickson GB, et al.  A proposed approach to allegations of sexual boundary violations in healthcare. Joint Com J on Quality and Pat Safety. September 01, 2023.
8. 59th Medical Wing Instruction 44-175 Medical: Chaperone.  July 2019.   Accessed at on 17 July 2024.
9. American College of Obstetricians and Gynecologists Committee Sexual misconduct. ACOG����dz������ٳٱ����Opinion������.��796. Obstet Gynecol 2020;135:e43–50.