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What if Your Patients Don't Want to Take Their Clothes Off?

Discussion in 'Doctors Cafe' started by Ghada Ali youssef, Jan 8, 2017.

  1. Ghada Ali youssef

    Ghada Ali youssef Golden Member

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    Getting Undressed at the Doctor's Office


    Most patients understand that going to a physician involves a physical examination that may require removal of some or all of their clothing. And although they may not like being undressed in front of a stranger, they accept it as a necessary inconvenience of medical care. But some patients are particularly uncomfortable.

    Responding to patient concerns about modesty is important not only for the patient's sake but also for the physician's, "especially in today's healthcare environment, with its emphasis on patient-centered care, process improvement, and quality," says Jack Chou, MD, director of the American Academy of Family Physicians and a family physician in Baldwin Park, California.

    "We as physicians need to be sensitive to their discomforts and responsive to our patients' needs," says Dr Chou. "Through surveys and other means, we need to ask patients what they want."

    Understand Your Patient's Modesty

    Patients have many reasons for their sense of modesty, says Caryn Andrews, PhD, CRNP, Faculty Of Medicine, Hebrew University School of Nursing, Jerusalem.

    Dr Andrews, an oncology nurse formerly associated with the Alvin and Lois Lapidus Cancer Institute, Northwest Hospital Center, Randallstown, Maryland, has extensively studied reasons for patient modesty. Her research has identified cultural and religious concerns; a sense of personal vulnerability, often stemming from previous trauma; and embarrassment about body appearance, such as aging or being overweight. Understanding the reason for your patient's discomforts enables you to provide more targeted reassurance, she says.

    Patients who appear unusually anxious may need the visit to be conducted in stages, says Dr Andrews. "I saw a patient who was shaking and nervous. I told her we would use today to get to know each other and conduct the examination another time. After two or three visits, she revealed that she had been raped. After discussing this, she was more comfortable being examined."

    Maura Quinlan, MD, MPH, section chair of the Illinois chapter of the American College of Obstetricians and Gynecologists and academic director of the Department of Obstetrics and Gynecology at MacNeal Hospital, Berwyn, Illinois, adds that reassuring patients about their physical appearance is important. "Some women going through the menopausal transition feel uncomfortable about their aging bodies. Teenagers often feel their genitalia to be 'flawed' or 'disgusting' and need education and reassurance."

    Some physicians want their patients to wear gowns because gowns provide rapid access to the entire body. But that degree of access is not always necessary, says Dr Chou.

    "Patients coming in for a common cold don't need to disrobe and put on a gown. A patient with diabetes may need to take off shoes and socks. But a physical may necessitate breast, pelvic, or rectal exams, so the patient should be wearing a gown. The amount of disrobing is disease-specific."

    It may be appropriate to allow patients who are extremely uncomfortable with a gown to wear their ordinary clothes, removing what is necessary as the exam progresses, adds Aasim I. Padela, MD, assistant professor of medicine in the Sections of Emergency Medicine and General Internal Medicine, University of Chicago. Although this is not ideal, the willingness to accommodate cultural or personal sensitivities is an important component of building trust and respect.

    Respecting Cultural and Religious Values

    Many cultures, including Asian, Hispanic, Muslim, and Jewish, emphasize the importance of same-sex providers in intimate examinations. Familiarity with these parameters sensitizes you to your patients' needs.

    In Islam and ultra-Orthodox Judaism, for example, certain female body parts may not be exposed in the presence of a man who is unrelated by blood or marriage. Unrelated men and women may not have physical contact. Studies of Chinese women have found that many avoided mammography or cervical screening until they were assured that a female technician would conduct the test.[1]

    Every attempt should be made to accommodate cultural and religious sensitivities, emphasizes Dr Padela. This includes providing gender-concordant care when possible, and finding creative ways to honor requests regarding clothing and physical contact.

    Although familiarity with cultural and religious mores is important, it is equally important to avoid making assumptions. Even within a given culture or religious tradition, there are individual variations, so always ask patients about their own needs and preferences.

    Will Having a Chaperone Help Protect Patient Modesty?

    Recommended by the American Medical Association and required by certain states,[2,3] chaperones ostensibly protect patients' dignity. But in reality, they may serve the needs of physicians rather than of patients, by protecting the physician from potential accusations of sexual impropriety, says Joel Sherman, MD, a retired Connecticut-based cardiologist, who blogs about modesty.

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    "The presence of an extra person at intimate exam can increase the patient's embarrassment. And it may be more difficult for patients to discuss sensitive issues with the physician if another person is in the room."

    It should be the patient's choice whether to have a chaperone in the room, Dr Sherman states. The subject should be brought up in advance, so patients are not caught off guard.

    And chaperones should be trained medical professionals of the same gender as the patient. If your facility or state requires a chaperone, explain this to the patient and assure the patient that the chaperone is not actually "watching" the exam. It may help if the chaperone stands or sits at a distance from the examination table.

    It is advisable to ask a patient who refuses a chaperone to sign a waiver, and if you are uncomfortable without a chaperone present, you have the right to tell that patient that you cannot perform the exam, Dr Frampton says.

    Some patients may prefer a family member or spouse to be present instead of a chaperone. This simple solution promotes patient comfort while protecting the physician

    Men May Be Modest, Too

    Male modesty has received relatively little attention, Dr Sherman observes. Fewer female physicians involve chaperones when examining men than do male physicians who examine women,perhaps because modesty has historically been regarded as pertaining only to women. But men should be accorded the same respect as women, he emphasizes.

    The Role of Office Staff

    The demeanor and attitude of your nurses are key to putting patients at ease. So, Dr Chou recommends "customer service training" for staff. "They can tell the patient matter-of-factly to put on a gown, or they can show empathy." He encourages the nurses to explain the rationale behind undressing if the patient seems reluctant.

    "I have a great medical assistant who reads the situation," says Dr Quinlan. "For example, if an adolescent patient is nervous or about to cry, she does not ask her to take off her clothes, because I will talk to the patient before any exam takes place."

    Building trust begins before you even step into the examination room. Some physicians opt to first meet with the patient in their office, where they can explain the nature of the examination in advance. Others prefer to have the patient already prepped in the examination room.

    Even if you have already spoken with the patient in your office, continue to explain what you are about to do and its rationale at every step of the way during the examination, advises Dr Quinlan.

    The Gown Makes a Difference
    Paper gowns compromise modesty, observes Susan Frampton, PhD, president of Planetree, a not-for-profit organization that "promotes patient-centered care." "They are skimpy, they rip easily, they do not close properly, and they leave the patient's backside exposed."

    Some physicians use paper gowns because they are perceived to be more sanitary, but cloth gowns are more comfortable and modest.

    "We use cloth hospital gowns, asking patients to leave the opening to the front," reports Dr Quinlan. "This makes it easier to uncover one part of the body while leaving the rest covered. When a gown closes in the back, a larger portion of the patient is exposed during an examination."

    Adjust the Physical Environment

    A space that is conducive to modesty fosters trust, says Dr Frampton. So make sure the examination table is not visible from the hallway when the door opens, that curtains in dressing rooms close properly, and that windows in the office have shades.

    Keep the scale in the examination room rather than the hallway so that patients do not need to leave the room once they have undressed. Hanging a "do not disturb" sign on the door deters others from knocking or interrupting during an examination, which can feel invasive to the patient.

    "When we undertook process improvement, we experimented with positioning the exam table," Dr Chou reports. "My nurse actually sat on the table as a way of understanding patients' experiences, and this informed some of our changes."

    Dr Chou and his staff decided to cover the overhead fluorescent lights with an acrylic design of the sky with clouds and to hang posters of beach scenes on the wall to create an environment that would be relaxing during examinations.

    Being cold can increase a patient's sense of vulnerability, not to mention physical discomfort. "We try to adjust the room to a comfortable temperature," he says.

    Patient Modesty in Hospital Settings
    Many large healthcare facilities are not conducive to patient modesty. Hospital policies, the patient's medical condition, available staff, and the often-frenetic pace mean that physicians cannot always adequately accommodate patients' concerns.

    Your demeanor and affect are critical to putting patients at ease, especially when time is short and other means of patient support may be missing, Dr Frampton says. Courtesy, empathy, and explanation are as important in the hospital as they are in your office.

    Many patients find open-at-the-back hospital gowns to be demeaning. Some hospitals are experimenting with innovative gowns, including wrap-around or kimono robes, or shorts to wear under the gown. And in many circumstances, patients can wear their own pajamas. Dr Padela urges physicians to accommodate patients' requests for more modest attire, even allowing the patients to wear their own clothing if not medically contraindicated.

    And try to find a same-sex physician at your facility for patients who request it, he adds. As the concept of the "healthcare team" expands, it may be possible to ask a same-sex provider, such as a physician assistant or nurse practitioner, to examine the patient if no gender-concordant physician is available.

    Conclusion

    "When patients come to see us, they are uncomfortable and often ill," Dr Chou comments. "We as physicians need to make sure we do not create further unease and foster our patients' feeling comfortable." Honoring a patient's sense of modesty is key to creating an environment of trust, comfort, and safety.

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