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...

Monday, 1 December 2008


Dear Bloggers

Today I wanted to discuss about Dignity and Privacy for patients. By passing on helpful situational anecdotes, I would hope that you as medical students and physicians will not make the similar mistakes.

Remember, patients are human beings with as many rights in law as you. No patient should ever be examined without their expressed permission unless the patient cannot give permission and in doing so, it is in their best interests as determined by the physicians and family and pertaining to the law of the land and which should be the overriding objective of medical care.

However, despite the patient giving you as doctors permission to examine them, it does not give you free will to do what you please. You must ask the patient to reposition themselves if you want to check particular parts of the body. You must not do it for them unless they ask you, or agree for you to do so. To intervene and manipulate the patient without their consent might be construed as an assault - so be careful.

An example from the UK was when I was training for an examination. On that day, I was training with a colleague and we went to examine a male patient who was well, had clear consciousness and was very compliant with verbal requests. I examined first and following that, my colleague examined the patient's cardiovascular system. Everything was going well and the patient turned his head to the left for the JVP to be examined and then suddenly, the patient lifted his head off the pillow to answer a question. As if like a reflex, the female doctor used the palm of her hand and pushed his head back down on to the pillow. The patient appeared somewhat bemused by what had just happened.

This type of physical contact was clearly wrong and the error was pointed out to the female doctor who promptly apologised to the patient for her error and the doctor then completed her examination.

If the above had occurred in a real life examination, the doctor would have immediately failed for not considering the care and comfort of the patient and for over stepping the permission granted by the patient for the doctor to carry out the examination.

In this scenario, the patient should not be restrained from simply moving. We must ask the patient with words not to move and certainly not entertain physical restraint of any kind.

However, putting physical examination aside for just a second, if the patient is clearly confused (and unable to make a logical decision) and that restraining the patient is in their best interest and to refrain from doing so might be otherwise detrimental to the physical and mental well being of the patient i.e. self-harm, then to do so might be appropriate. In any such situation, you must be aware of the local and national laws of physical restraint to safe guard yourself as well !

If the patient is compos mentis and decides not comply then so be it. We must not take it upon ourselves to do what the patient might not want us to do. We must at all times re-examine our own decision and that of the patient whether certain parts of the physical exam can be continued because of patient compliance. Patients can revoke their decision to be examined at any time! Just remember that.

Another example was in Japan some years ago when I saw the very same 'palm-to-forehead restraining manoeuvre' to stop a patient from lifting their head up to talk. This was wrong. The junior doctor had not realised that this was an inappropriate way to treat the patient.

On the other hand, sometimes weak patients need help to be sat up in order that the chest can be properly examined, but again, patients should be treated with respect and dignity, all the time asking them if it is acceptable to continue the physical examination.

How can we learn what is right and wrong ? That comes down to ethics training at University and through our own quest to understand what is socially and ethically acceptable within our own society.

Another thing to remember when examining patients on a general ward is PULL THE CURTAINS! Patients expect privacy and again I mention it, DIGNITY. As medical staff we are used to seeing the human body every day and over time we probably become desensitized to the meaning of privacy. However, we must put ourselves in the position of the patient and think what they would want. Most patients would not want to be exposed for everyone to see across the medical bay. Pulling the curtains on a main ward is not a difficult thing to do. All it takes is to understand the patient's needs and not just your own.

Moreover, if a doctor walks into the examination area around the bedside -- RE-PULL THE CURTAINS. Don't leave gaps in the curtains for others to peer through. It is simply not the done thing.

When examining the patients remember to refasten the clothes after having exposed the patient and completing the examination. Don't leave the patient lying on the bed, clothes open for everyone to see when there is no need to. Again, it comes down to PRIVACY & DIGNITY for the patient. Only expose those areas that you are currently examining. Don't completely expose the patient in one go.

Lastly, despite medical students and junior residents being eager to learn physical examination, it does not mean that 10 people try and clamber behind the examination curtains especially around a cramped bedside. Remember, PRIVACY & DIGNITY for the patient. A patient does not want 10 freshmen gawping at their chest during auscaultation when the main problem is the cellulitis of the leg. If you are going to teach in numbers, remember that the patient must give permission first. Do not make the patient feel pressurised to accept a troop of physicians when it is not what they want. If in agreement, try to limit your examination in front of a crowd as much as possible to maintain the PRIVACY & DIGNITY of the patient.

Remember, unhappy patients complain which could mean you coming before a board of inquiry for your actions even if you thought you were right. A happy patient will not usually complain about you. If you do examine the discrete areas i.e. breasts, genitourinary system of a female patient, please have a chaperon present at all times as a means of protecting you and the patient from what could, for example, be potentially misinterpreted as a sexual assault, and please document your findings accurately and state the name of the chaperon and their seniority e.g. senior staff nurse. If a patient complains about you and the allegations are untrue, the chaperon may be the only person who can give an independent account of what happened to save your neck.

Remember, protect the patient both physically and psychologically and you therefore protect yourself. Don't overstep the mark as a doctor. Paternalist medicine went out the door many years ago in the UK and USA. These days the patient is empowered and the physician must seek agreement with the patient.


Thank you for reading today :-)

For further reading, there are many books available on medical ethics and such texts are well worth a perusal.

Please carefully consider....

If you have any views on the above or on medical ethics generally then drop me a line and get published! I look forwards to hearing from you.