Tuesday, 2 December 2008


Dear Bloggers

Professor Alan Lefor of Jichi University, Japan has kindly provided additional important comments in regards to Privacy and Dignity.

I would emphasize a few things. I don't know if all of this applies here, but it certainly does in the USA

1. Chaperons are critical, especially for male doctors examining female patients.

2. I get the history from a dressed patient, then I leave the room while they get undressed. I use that time to quickly write up the history.

3. I always have the patient remove all of their clothing (EVERYTHING!) and put on a gown, and then during the exam, I ask the patient to expose their body by pulling the gown up. I never do that to the patient. Then, when the gown is up, I quickly use a sheet to cover the patient's body except exactly where I need to examine.

4. After the physical exam I leave the room so the patient can get dressed in privacy. I use that time to collect my thoughts and write up the physical exam. Then I go back in and talk about the plan to a fully dressed patient.

Privacy & Dignity cannot be over-emphasized.

These are my additional thoughts. The comments you made are critically important!

Thank you Professor Lefor for such important advice.

Professor Lefor has provided insight into how privacy and dignity of the patient in respect of physical examination is maintained in the United States.

In the UK, most clinic rooms are 'double rooms' consisting of a consultation room and an examination room. Depending on the nature of the consultation, the patient may need to use a gown but in all cases, the patient is draped when required. The doctor enters the room after the patient has made themselves comfortable for the exam and the doctor leaves the room in order to allow them to redress and come back through to the consultation room. There is a clinic nurse present in order to assist the physician and patient and of course, to be the ever important chaperon.

However, in Japan, matters can be very different. On occasion, outpatients can consist of multiple thin-walled cubicles making privacy and confidentiality a potential problem because of acoustics. Doctors are usually rushed because of the high patient turnover in the outpatient clinic and can at best only spend 5 mins or so with each patient. In a typical morning clinic, such doctors might easily see 40 patients. One surgical friend of mine saw 120 patients in a day! No joke!!

Ultimately, history taking and physical examination are limited with most time taken up by typing into the computerised records (denshi kalte) and ordering lab tests and radiology. The turn over is very rapid, although it depends upon the specialty, and the doctor does not get the opportunity to step outside the cubicle. Privacy is maintained in some respect by pulling a curtain around the examination couch. Draping the patient should be done, but again, it depends on local practices, resources and time available. Chaperons are available on request.

In an ideal world, the patient should be given ample time for a full history, physical examination, the full consideration of all the problems at hand and step-wise assessment and plan. However, in reality, not all the elements can be carried out in such a limited and stressful situation.

In Japan, one way to reduce the flux of patients into the hospital outpatients would be to introduce a fully comprehensive community-based primary care service, as in the UK (general practitioners), who see the patients registered in their locality. They are the gatekeepers to the local hospitals and decide who needs to be seen by a particular specialist at the hospital or whether the problem can simply be managed in primary care. This system works extremely well in the UK whereby the GPs only refer sick patients who may need hospital admission. Non-acute problems are referred by letter for an appointment directly to the consultants in the local hospital (if required). Patients cannot simply turn up to the hospital outpatient clinic unannounced.

As such, patients have a longer time to spend with the consultant or registrar during their booked outpatient appointment, and a fuller understanding of the patient problems can be elicited and physical examination can be carried out in detail. Usually, a new patient will get 20-30 minutes and a follow-up patient 10 minutes. In a busy clinic in the UK, a physician might see perhaps 12-16 patients but usually no more than that.

If there were more Primary Care physicians in Japan, the stress on the hospital outpatient system would be much less. However, at present, there are not many Primary Care / Family Practise training schemes in Japan. I would hope that this will change in the future.

Please consider...

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