Sterling Ransone, Jr, MD, a family physician in Deltaville, Virginia, knocked on the exam room door and entered to find the patient, a 28-year-old woman, seated on the examination table. She was complaining about a fever, sore throat, and congestion.
Ransone asked if it was okay for him to lift her shirt and listen to her heart. She shook her head slightly. He decided to listen without removing the clothing, but when he put one hand on her shoulder and the stethoscope on her back, she flinched.
Instead of proceeding with the examination, Ransone, who is president-elect of the American Academy of Family Physicians, asked the patient whether everything was okay. It turned out that she had been the victim of a sexual assault and did not want a male to remove any clothing or touch her chest or back. Fortunately, Ransone's practice had a female partner, who came in and listened to the patient's chest.
"I'm glad I asked the patient what was going on for her because otherwise, I wouldn't have known what she was going through," Ransone said. "The patient felt respected and safe, and the therapeutic relationship was enhanced instead of compromised."
Patient dignity is one of Ransone's most important professional values. He recounts that during rounds in medical school, the attending and several interns and students crowded into the semiprivate room of an elderly woman who was lying in bed. The attending pulled off the bedcovers, leaving the patient exposed while he discussed her case.
"I was mortified for her, and I learned a lot from watching this unfold, just seeing this woman lying naked in front all of these strangers and God," said Ransone, who is also physician practice director at Riverside Fishing Bay Family Practice, Deltaville, and assistant clinical professor of family medicine and population health at Virginia Commonwealth University, in Richmond. "I've been in practice for 25 years, and making sure the patient feels comfortable and respected is one of my priorities that dates back to that very first encounter."
Trauma-Informed Care
Trauma is a common reason why patients feel reluctant to remove their clothing, according to Lauren Radziejewski, DNP, ANP-BC, clinical program manager, Mount Sinai Center for Transgender Medicine and Surgery, New York City.
"We teach and endorse trauma-informed care for any type of procedure that is potentially triggering, and I would certainly put any type of care where people have to take off their clothes as potentially triggering," she said.
Trauma can be caused by many factors. "Traumas of a sexual nature — having been subjected to sexual violence, for example — are the most obvious that come to mind, but any trauma that involves violation and disempowerment, even a nonsexual one, can make people more reluctant to be in a sensitive situation that can be perceived as invasive or disempowering," Radziejewski said.
Talk Before You Touch
There are other reasons, often multiple intersecting reasons, why patients are reluctant to disrobe, according to Alicia Arbaje, MD, MPH, PhD, associate professor of medicine and director of transitional care research at the Center for Transformative Geriatrics Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland. These include culture and religion, generational sensitivities, and body discomfort associated with transitional times in life (eg, teen or menopausal years).
Some general approaches apply, regardless of the reason for the patient's discomfort. Others are specific to the patient's particular problem or concern, Arbaje said.
"So much of medicine in this day and age is to quickly get down to business, hurry, and move on to the next patient," said Arbaje, who also serves as chair of the American Geriatric Society's Public Education Committee. "But establishing a little bit of a relationship is crucial before beginning the physical exam with any patient, especially with seniors or other patients who might have particular discomforts."
She advises practitioners to "spend time talking before touching." In other words, "Find a way to create some kind of meeting, even very briefly, and establish rapport before the patient changes into a gown and before you touch the patient to examine him or her."
She acknowledged this might be difficult to do in certain clinical settings, but "to whatever extent you can, try to build this extra time and extra step into your workflow."
She suggested that physicians first meet with the patient in the office or examining room to hear about his or her concerns. If a gown is necessary, the patient can change into one after the physician leaves the room. This builds trust and rapport.
Choice of language is important, especially when talking with older individuals. "Address the patient by their title until you are told not to — Ms or Mrs Smith, or Mr Jones — or ask, 'How would you like to be addressed?' And don't use terms of endearment, like 'dear' or 'sweetie,' or the plural, such as 'How are we feeling today?' " These are "infantilizing and patronizing" and can impact the patient's level of comfort with the entire appointment, including undressing and being examined.
Regarding transgender people, "many have experienced sexual violence and inappropriate touching, but even those fortunate enough to have escaped that type of common problem typically have still undergone traumatic experiences just by being transgender, having been socialized incorrectly, misunderstood, or having the 'wrong' genitalia," said Radziejewski.
Particularly when dealing with a transgender patient, "you have to assume that there may be a history of trauma. Be sensitive to the patient's discomforts about disrobing, recognize the examination itself as a potential trigger, and take appropriate measures to mitigate the trauma."
To do this, Radziejewski gives her patients a "menu of options," because "when people are navigating the world after trauma, including marginalized identity, they often have a complete loss of control, so the key is to give them as much control as possible every step of the way."
For example, Radziejewski might tell a transgender masculine patient, "I'm looking through your chart and see no documented Pap test." She acknowledges that after explaining why the test is recommended, the patient might be uncomfortable with it. She then makes a series of suggestions that range from being completely noninvasive to more invasive.
"You can say you don't want it at all, or you can take a swab that I will give you and do it in the bathroom yourself. If you're more comfortable with a man performing it, I can arrange that, or if you're more comfortable with someone other than myself — your regular provider — I can arrange that, too." By the end of the interaction, most patients are comfortable with Radziejewski performing the exam.
Regarding invasive exams, she recommends setting up an appointment specifically dedicated to that exam, rather than trying to cram a sensitive process into the time allotted for a patent visit, when other topics are also being discussed. "This also reinforces a sense of control," she said.
This approach is relevant not only for transgender patients but also for any patient who has experienced trauma or some type of shame associated with the body, she said.
Ransone asks transgender patients what pronoun they would like him to use when he addresses them.
Prior to the examination, talking about what will be done and why further enhances trust, comfort, and rapport.
Who Should Be Present?
Arbaje suggested that the pre-examination conversation should include a discussion of who the patient would like to have present during the exam. This is particularly relevant with a geriatric patient who might have been brought in by a family member or caregiver.
Similarly, adolescents may not feel comfortable with a parent being present for an examination. To protect the teen's privacy, Ransone asks parents to step out. "There are also subjects that adolescents won't bring up if their parents are there," he said.
A question that is relevant in many clinical settings is whether the presence of a chaperone enhances or detracts from the patient's comfort. Although the use of chaperones is recommended by many societies, it is a judgment call whether a chaperone should be present during all examinations — unless the state in which one practices requires it. Seven states mandate the presence of a chaperone during an intimate exam: Alabama, Delaware, Georgia, Montana, New Jersey, Ohio, and Tennessee.
Ransone utilizes a medical scribe to take notes on patient visits. The nurse or medical assistant who escorts the patient into the exam room informs the patient that a scribe will be in the room but that the patient should feel free to say whether he or she wants to talk about something privately, in which case the scribe will leave.
Ransone's scribe is female and serves as the chaperone during an intimate exam of a female patient. "I have assumed, and my established patients know, that there will be a chaperone present, but my patients also know they can ask for the chaperone to step out," he said. "When that happens, I document the discussion in the patient's chart for my own legal protection."
He recommended that practices consider posting signage or including information about chaperones in the practice's informational brochures regarding policies and procedures.
Armin Brott, MBA, senior editor of Talking About Men's Health , said that having a chaperone in the room when a female practitioner is examining a male patient — even if the chaperone is male — would be "extremely uncomfortable, weird, and even voyeuristic for the male patient."
He noted that typically, male physicians use a chaperone when examining a female patient "for their own legal self-protection and maybe to make the female patient more comfortable, but female physicians are typically less concerned about potentially being accused of violating a male patient and typically do not have chaperones."
Men Face Unique Challenges
Men have "unique needs and challenges" when it comes to healthcare, said Brott, an advisory board member of the Men's Health Network.
Brott cited research showing that men do not seek healthcare as frequently as women do. "So it's already hard to get men in the door of a doctor, no matter what the provider's gender is," he said. Notably, men are even less likely to seek medical care when the clinician is female, owing to discomfort at having to undergo an intimate exam.
"I think that many men have issues about sexuality and of becoming aroused during an exam if it's a female practitioner doing the exam," said Brott. "I'm sure this is something physicians and nurses are accustomed to, but for the patient, it's extremely embarrassing. The man may worry that he'll be perceived as making unwanted sexual overtures to the practitioner."
The way to mitigate these concerns is through communication, according to Brott. He recalled his own experience during a catherization conducted by a female practitioner he had never met. "She came in and started dealing with me as if I wasn't even a person. She didn't say much. It would have helped if she had created some type of human connection and talked to me — something like, 'I've done this a thousand times and here's what you'll be feeling,' or, "Would you like me to describe what I'm doing, or just do it as quickly as possible?'"
On another occasion, Brott underwent a procedure that was performed by two female practitioners, who were more communicative and even brought some light humor to the encounter, "which set me at ease," he said.
If a man does become aroused, reassurance would be helpful, Brott said. "You can say something like, 'Don't worry, it's perfectly natural, it happens all the time. Let's finish up, and I'll be out of your way as soon as I can.'"
Explain at Every Step of the Way
All the experts emphasize the critical importance of continuing to offer explanations throughout the exam, even if the exam has been discussed beforehand.
"During the exam, it's key to explain what you're doing each step of the way — especially with seniors, but with other patients too," said Arbaje. "For example, 'I'd like you to remove your arms from your shirt so I can examine the joint better.' Often there's apprehension about what you're going to do next. You can also ask, 'Is there anything I should know before I examine this part of you? How are you doing?' " She advised asking the patient for "ongoing feedback. 'Is this okay? Is this too rough?' "
This is especially important when conducting a pelvic exam or palpating the patient's abdomen, which is a more personal area than, say, the knee. Only the body part that is being examined should be uncovered, and it should be re-covered after the exam of that body part is complete and a different body part is to then be examined.
Asking for feedback is especially important, because many older patients have been acculturated not to question physicians and other medical authorities and may suffer a sense of humiliation silently.
Arbaje noted that feedback can be nonverbal: "For example, wincing or flinching are signs of discomfort you should ask the patient about or empathetically acknowledge."
Rapport Building Doesn't End After the Examination
Arbaje advises physicians to "spend a little more time with the patient after the examination and not just walk out the door, leaving person as they are, half undressed or in a gown."
In the case of an older person, this might involve helping patients get their shoes and socks on or helping them get off the table. "Spend some time closing the encounter, not just doing what you need to do and then leaving or leaving it for someone else or family to do, which can be very dehumanizing," she said. Even a few minutes of human contact beyond the examination can enhance rapport and help the patient feel respected and more comfortable.
Setting the Stage: Create a Conducive Office Environment
Setting patients at ease begins well before the patient enters the examination room, experts say. The overall atmosphere of the practice ― the professionalism, courtesy, and friendliness of the staff ― contributes to a sense of safety that will set the stage for the patient to feel more comfortable disrobing, if necessary, and being examined.
Brott pointed out that most medical offices tend to be more "female-friendly" in decor, utilizing pastel colors and flower motifs, for example, and displaying women's magazines in the waiting room. Gender-neutral decor and different types of reading materials might set men at ease. Receptionists and medical staff are often female, and it is helpful for practices to employ male staff to bring the patient into the examination room or check vital signs. "This would go a long way toward making a man feel welcome and comfortable, even if the physician is female," he said.
Radziejewski agreed: "If possible, having male and female support staff available will set patients of any gender at their ease."
The setup of the examination room may contribute to a patient's level of comfort. In Ransone's examination room, the patient faces the door when on the table, and the door is locked during the exam so that no one can enter.
"I think that if patients are facing away from the door, they may feel claustrophobic or trapped, and I don't want to position myself between the patient and an exit," Ransone said. "My exam room happens to have no windows, but I've seen situations where the patient is lying on the table, exposed in front of the window, which can feel vulnerable, even if the office is on a high floor and no one can see into the window."
Ransone positions the scribe or chaperone to the side, where the patient can see them, but not directly in front, where the examination might be visible to them. "I think it would be more uncomfortable and anxiety provoking knowing that someone is standing behind me and I can't see them," he said.
Choosing the Best Gown...When Necessary
Is it necessary for patients to disrobe and put on a gown — especially in light of the fact that research suggests that wearing a gown can induce psychological distress?
Danielle Ofri, MD, PhD, clinical professor, Department of Medicine, NYU Grossman School of Medicine, New York City, said that in her practice, patients wear street clothes unless the patient is to undergo a full physical exam.
Even an abdominal exam can be conducted by loosening and slightly lowering the pants. Ofri stresses that patients should retain full control over how much to expose: "The patient should always take the lead in adjusting or opening clothing for a focused physical exam. And, of course, we always need to ask permission before starting any part of the exam."
A gown is more conducive for certain exams, such as pelvic or breast exams. Ransone said that cloth gowns are preferable to paper gowns, which can tear more easily and so lead to unnecessary exposure. Gowns that hang open at the back should be avoided. If that's the only type available, a second gown can be provided so as to cover the backside.
This is especially important if the examination involves walking across the room — for example, to evaluate gait — or standing on the scale. Alternatively, the patient can be given a sheet to drape over the gown, which can be moved around during the examination.
Ransome's own practice uses gowns that fully wrap around the person. "I've seen too many people in gowns that are too small, so I make sure the patient has an appropriately sized down. The extra material also leaves room for draping, while exposing only the part of the body that's necessary," he said.
Numerous types of modest gowns are now available, including kimono-type gowns with ties and snaps that allow partial exposure. All the experts encouraged utilizing these or similar types of gowns if possible.
Cultural and Religious Considerations
It is important for clinicians to be sensitive to cultural and religious factors that might affect patients' attitudes toward attire and opposite-sex practitioners, said Ofri, an internist at Bellevue Hospital, New York City.
For example, in Islamic and ultra-Orthodox Jewish traditions, certain parts of the body may not be exposed in the presence of a man who is unrelated by blood or marriage. Studies have shown that Hispanic and Asian women have avoided mammography because of embarrassment.
Arbaje described a 90-year-old patient whose physician ordered a pelvic ultrasound. The ultrasound department conducted the test transvaginally. "The patient, a widow, came from a Catholic background and regarded this as tantamount to 'cheating' on her deceased husband, and she felt violated and ashamed," Arbaje said.
Ofri, who is the author of Medicine in Translation: Journeys With My Patients, said that she has Muslim and Orthodox Jewish male patients who allow her to examine their knees but won't shake her hand because of the prohibition against touching an unrelated woman. Muslim female patients are willing to unsnap their veils because Ofri is female, but they would be uncomfortable with a male practitioner.
Whenever possible, gender-concordant care should be provided. If that is not possible, patients should be offered the option of not undergoing the examination, unless it's an emergent situation, Ofri said. It may be necessary to reschedule the appointment to a time when a same-sex practitioner is available or to refer the patient to another practitioner.
Keeping cultural and religious considerations in mind is important, but there are variations in any given culture or religion. Practitioners should take cues directly from the patient, the experts advise.
Meeting the Needs of Cognitively Impaired Patients
Patients who are cognitively impaired have particular needs, Arbaje says. Many such patients are seniors with dementia, although developmental disabilities, neurodegenerative diseases, and other problems that affect cognition can occur among patients of any age and stage of life.
"People with dementia don't necessarily understand what you're doing and why you're touching them. Even people with advanced dementia often retain a sense of modesty and may feel humiliated by an examination," Arbaje said.
Arbaje encourages offering clear explanations of what is being done. The language one uses should be respectful and nonpatronizing, even if the patient does not understand what is being said. However, the bulk of one's communication should be nonverbal. "Convey gentleness, safety, and reassurance through your tone and touch," Arbaje said.
For cognitively impaired patient, it is helpful for a trusted family member or caregiver to be present during the examination, rather than a stranger. Depending on the degree of impairment, it might also be helpful for them to have a familiar object, perhaps a blanket; the odor and texture can convey familiarity and reassurance.
Nonclinical touch can also be reassuring. "We're often scared of touching a patient because we don't want to be considered inappropriate, but people who have dementia in later life are often understimulated, in terms of loving and caring touch," she said. "For people in that situation, touch is typically of a practical or clinical nature — like bathing the person or taking their blood pressure. Providing reassuring touch or having someone else present to do so can help ease the patient's fear and can be very healing."
Making Your Patient's Eyes Light Up
"I can't even count how many times I've had patients thank me for just explaining things clearly and giving them the right to opt out of wearing a gown or having an examination or procedure," Radziejewski said.
"Obviously, I express recommendations, strong recommendations, but people like to know this is a place where they'll be acknowledged for who they are, where they can feel safe and their dignity will be preserved. That should be the environment for any patient, whatever their culture, religion, age, background, or sexual identity. Offering that type of venue makes their eyes light up and makes all the difference in adherence to my recommendations and feeling empowered to truly care for their health," she said.
Suggestions for Further Reading
Patient Medical Modesty: For Healthcare Professionals.
https://patientmodesty.org/medical.aspx
Office of Diversity and Inclusion. Cleveland Clinic. Diversity Toolkit; 2017. https://my.clevelandclinic.org/-/scassets/files/org/about/diversity/2016-diversity-toolkit.ashx
Ehman J. Religious Diversity: Practical Points for Health Care Providers. Penn Medicine Pastoral Care and Education; 2012.
https://www.uphs.upenn.edu/pastoral/resed/diversity_points.html
Deutsch MB (ed). Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, Second Edition. Center of Excellence of Transgender Health, UCSF; 2017.
https://transcare.ucsf.edu/sites/transcare.ucsf.edu/files/Transgender-PGACG-6-17-16.pdf.
Galanti GA. Caring for Patients from Different Cultures, 5th ed. University of Pennsylvania Press; 2014.
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