Chaperone Use by Residents During Pelvic, Breast, Testicular, and Rectal Exams

Abstract

We designed a questionnaire survey to study internal medicine residents' plans to use a chaperone during the pelvic, breast, rectal, and testicular examinations. We found chaperone use by male and female residents differed markedly, and neither group planned to use chaperones universally. When examining female patients, male residents overall were very likely to use a chaperone during a pelvic exam, but less likely for the breast exam and rectal exam. For the female resident, there was a significantly lower likelihood of using chaperones during the pelvic, breast, or rectal exams. There was a much lower rate of chaperone use during the sensitive portions of the male physical examination compared with the female examination, with somewhat higher use by female residents. We concluded that male and female residents differ significantly in their patterns of chaperone use. It would be valuable to develop guidelines for chaperone use to help residents understand the issues involved in the choices, and to protect the residents from the possible medico-legal consequences of forgoing chaperones.

Among practicing physicians, there is diversity in their use of a chaperone during sensitive portions of the physical examination. For many male physicians, it is customary to have a chaperone present during a pelvic examination of female patients. Among women physicians, the tradition differs, and chaperones are used less frequently. Reasons typically cited to justify the use of a chaperone include medico-legal protection for the physician, the need for an assistant, and custom.^1,2

The training students and residents receive about chaperone use also varies. One physical diagnosis textbook³ commonly used by medical students advises that during the gynecologic exam, “male examiners are customarily attended by female assistants. Female examiners may or may not prefer to work alone but should be similarly attended if the patient is emotionally disturbed.” Another textbook⁴ states that the pelvic exam “requires … attendance of a female assistant who also serves as a chaperone.” Use of a chaperone during the breast exam, rectal exam, or testicular exam is not discussed.

In 1996, the American Academy of Pediatrics⁵ published guidelines for chaperone use in children and adolescents, but guidelines for use of chaperones by physicians caring for adults have not been established. A recent study found no consensus among state medical boards regarding their use.⁶ In their paper about professional boundaries in the physician-patient relationship, Gabbard and Nadelson⁷ recommend the use of chaperones with patients with a known history of sexual abuse, who have extreme anxiety or a psychiatric disorder, who are litigiously minded, who are undergoing a pelvic examination, and who, for any reason, raise concerns in the physician.

Several studies of physician use of chaperones have been done in both the adult and adolescent populations.^2,8–11 However, these studies have not addressed the use of chaperones by resident doctors in training. We therefore surveyed residents in order to determine when they plan to use chaperones when examining patients in their outpatient office practices. We also examined characteristics of the residents and patients that might be found in a typical office setting to see how these would influence chaperone use.

METHODS

A questionnaire survey was developed and pretested for face validity. It was distributed to all categorical residents in the internal medicine, internal medicine/emergency medicine, and internal medicine/pediatrics programs at the Christiana Care Health System. Anonymity was assured since no questions had identifying features. The survey consisted of 13 vignettes describing typical doctor-patient encounters with male and female patients in the resident outpatient medicine office (see Appendix). Using a 5-point Likert scale, the residents were asked how likely they were to use a chaperone during a breast exam, a pelvic exam, a rectal exam, or a testicular exam (very unlikely, somewhat unlikely, neither likely nor unlikely, somewhat likely, very likely). The survey also collected information on demographics, as well as residents' perceived skill and comfort performing elements of the physical exam, and general attitudes about chaperone use. For the purposes of presentation, the Likert scales were collapsed such that “likely to do” included “very likely” and “somewhat likely.” The case vignettes were compared with control vignettes using χ²analysis and paired t tests. The effect of resident gender on control cases of vignettes was analyzed via χ²analysis. The association between patient age and chaperone use was analyzed using logistic regression.

RESULTS

Fifty-four questionnaires were distributed, and 47 (30 male, 17 female) were returned for a response rate of 87%. Thirty-two were internal medicine residents, 9 combined medicine/pediatrics residents, and 6 combined internal medicine/emergency medicine residents. Overall, 53% planned a career in primary care medicine.

Physician gender was the major determinant of chaperone use during the physical exams of both male and female patients (Tables 1 and 2). The physician's level of training, reported level of comfort and skill performing different aspects of the physical exam, and plans to practice primary care did not correlate with their plans to use a chaperone.

Table 1.

Residents Likely or Somewhat Likely to Plan to Use a Chaperone for Female Patients During a Breast or Pelvic Examination

	Breast Exam		Pelvic Exam
Characteristic	Male Resident, % (n = 30)	Female Resident, % (n = 17)	Male Resident, % (n = 30)	Female Resident, % (n = 17)
Attractive patient	77	6	93	41
Married	77	6	96	47
Divorced	77	6	96	53
Well-known patient	50	12	93	47
History of abuse	90*	47‡	77	59
First pelvic	90*	23	100	70‖
Crossed boundaries	93†	70§	100	70§
Control	77	6	96	47

^*P < .017

^†P >.001

^‡P = .008

^§P < .005

^‖P < .05.

Table 2.

Residents Likely or Somewhat Likely to Plan to Use a Chaperone for Male and Female Patients During a Rectal Examination, or a Male Patient During a Testicular Examination

	Testicular Exam		Male Rectal Exam		Female Rectal Exam
	Male Resident, % (n = 30)	Female Resident, % (n = 17)	Male Resident, % (n = 30)	Female Resident, % (n = 17)	Male Resident, % (n = 30)	Female Resident, % (n = 17)
New male	6	23	6	12
Well-known male	0	29	0	18
Well-known female					60	0

Patient gender, age, attractiveness, marital status, and how long the patient had been seeing the physician were varied to examine their impact on residents' plans to use a chaperone. Red flag characteristics expected to significantly increase chaperone use were introduced: a patient with a history of abuse, a patient who had previously crossed boundaries with the physician, and a patient having her first pelvic exam. Results are shown in Tables 1 and 2. Physician gender was the major determinant of chaperone use in both male and female patients. The age of the patient was inversely related to chaperone use by the male residents: the older the patient, the less likely they were to use a chaperone (P < .001, data not shown).

Residents rank ordered general reasons why they used a chaperone, and we analyzed their first choices (Table 3) Male residents most commonly use them for legal protection, female residents for technical assistance. Forty percent of residents believed that there was a departmental policy regarding chaperone use for the pelvic examination, 20% for breast examination, and 8% for the rectal examination. In actuality, Christiana Care does not have a policy but does make nurses available as chaperones.

Table 3.

Primary Reason for Using a Chaperone During the Physical Examination

	Male Residents, %	Female Residents, %
Protect me legally	60	0
Technical assistance	3	59
Patient comfort	13	18
Physician comfort	17	0
Taught to use	7	6
Never use	0	6
None of the above	0	6
Expected by attendings	0	0
Expected by patients	0	0

DISCUSSION

We have found that chaperone use by male and female residents differed markedly, and neither group planned to use chaperones universally. When examining female patients, male residents overall were very likely to use a chaperone during a pelvic exam, but less likely for the breast exam and rectal exam. For the female resident, there was a significantly lower likelihood of using chaperones during the pelvic, breast, or rectal exams. There was a much lower rate of chaperone use during the sensitive portions of the male physical examination overall, with somewhat higher use by female residents. Although this study did not examine barriers to chaperone use, there are certainly many that exist in our practice setting, the most important of which is probably the time it takes to find the nurse or medical assistant available for this purpose.

Prior studies of physicians in practice have also shown that use of chaperones when examining adults is variable, and that use by women physicians is less than that of male physicians. Renfroe and Replogle² surveyed chaperone use by primary care physicians in Mississippi and found 92.6% of male but only 64% of female practitioners always used a chaperone for the pelvic examination. Conversely, for the male genital exam, only 2.3% of male physicians used a chaperone versus 31.6% of female physicians. Their data is similar to our findings for residents. They also asked physicians for reasons to use a chaperone during female exam and found as we did that female physicians most commonly cited their need for assistance, while male physicians cited medico-legal concerns and customs. Speelman et al.⁹ in a 1993 survey of general practitioners in Great Britain found that female general practitioners never or rarely used a chaperone and felt comfortable examining a male patient without one. In addition, 65% of male general practitioners never or rarely used a chaperone or even intended to offer one. Only 16% of male practitioners always used a chaperone even though their “defense organizations advise the use of chaperones when performing an intimate exam on a patient of the opposite sex.” In 1999, Johnson et al.¹¹ published a survey of chaperone use by obstetrician/gynecologists associated with a tertiary care teaching hospital in the Northeast. They found that chaperones were not used universally during obstetrical exams, gynecologic exams, and breast exams, and that male physicians used them significantly more often than female physicians.

Patients do not always prefer the presence of a chaperone. One recent study of women seen in a community-based family planning clinic in the United Kingdom found that the majority of women preferred to be alone with a female provider during the pelvic examination.¹² Several other studies found that patient preference was strongly influenced by the gender of the physician, and there was increased preference for a chaperone during a breast or a pelvic examination if the physician was male.^13–15

This study has several limitations. Actual chaperone use was not assessed. Our estimation of use was in response to clinical vignettes and may not reflect actual use by the residents. The results also reflect the practices in one training program and may not be a reliable estimate of chaperone use by residents in general. In addition, there was a high level of chaperone use during the pelvic exam by male residents. This may have made it impossible for us to detect the effect on chaperone use during the pelvic exam of subtle patient variables such as attractiveness of the female patient, marital status, duration of the doctor-patient relationship, or red flags.

This study has implications for chaperone policies in resident outpatient offices. It would be of value to develop guidelines for the use of chaperones to help residents understand the issues involved in the choices, as well as to protect the residents from the possible medico-legal consequences of not using chaperones. We feel that issues involving the use of chaperones should be specifically addressed during medical student and resident training.

Appendix

The Scenario

You are a resident at the start of your office hours in your outpatient office site. You have already been fairly busy in the hospital today and you arrive about 1/2 hour late. You are in a hurry to get back to the hospital because you have an admission waiting for you on the floor.

You have a nurse or a medical assistant available if you need a chaperone during any of your visits, and you know from past experience that it usually takes about 5 to 10 minutes for them to arrive when you need them. We would like to know in which instances you will choose to use a chaperone during your physical exam.

Please read each of the following cases carefully and respond to the questions that follow.

The Vignettes

Case 1: Your first patient today is a 73-year-old woman. You are following her for management of hypertension, which has been under good control for the past 2 years. She is married and brings in photos of her granddaughter's wedding today for you to see. She is here for her yearly physical.

Case 2: Your next patient is a 38-year-old woman who went through a difficult divorce 2 years ago. You have seen her on many occasions to discuss the management of her high blood pressure, and recently she has become more compliant. She is happy today. She is finally getting her life back together and has found a new job. She is here for her yearly physical exam.

Case 3: Next you see an 18-year-old woman you have been following for the past year with ITP in remission. She is here today because her mother thinks it is time she had a pelvic exam. She has never before had a pelvic exam or a Pap smear.

Case 4: Your next patient is a 30-year-old woman you have known for 2 years who has recently moved herself and her children out of their home into a shelter to get away from an abusive husband. She is here for her yearly physical exam.

Case 5: Next you see a 27-year-old woman who is a student at Delaware Technical College. You have been following her for the past 2 years for management of adult onset diabetes mellitus. She is compliant with her medical regimen and checks her sugars frequently. She is here for her yearly physical exam.

Case 6: Next you see a 35-year-old man you have followed closely for the past year for management of his diabetes mellitus. He has done well on the oral agents, and both of you have been pleased by the results of his recent blood work. He is here today for his yearly physical exam and for the evaluation of some bleeding hemorrhoids. He is married.

Case 7: Next you see an attractive 25-year-old aerobics instructor whom you have followed since she was hospitalized for asthma 1½ years ago. She is one of your most compliant patients, and her asthma has been in good control. Over the 2 years, you have gotten to know her well and look forward to her visits. She is here for her yearly physical exam.

Case 8: Now you are seeing a 59-year-old woman you met 2 months ago when she presented with an acute sinusitis. At that visit, you determined that she was due for a complete physical. She is married and is a retired day care worker.

Case 9: Your next patient is a 51-year-old woman with asthma. You know her well and, in fact, care for her husband and her son. She is here for her yearly exam.

Case 10: Next you see a new patient. He is a 28-year-old man here for evaluation of dysuria. He is married, but has been with a new partner and is worried that he has “caught an infection.” He is also complaining of rectal bleeding.

Case 11: Your day continues along, and next you see a 29-year-old woman you have been following for adult onset diabetes for the past year. You remember her well because she has asked you out to dinner in the past (which you refused). She is here today for her yearly physical exam.

Case 12: Your office hours are almost over. The next patient is a 19-year-old woman you have followed for 2 years for migraine headaches. She is here today for her physical exam, but also tells you she is having some rectal bleeding.

Case 13: Finally, you see a 35-year-old woman you have followed closely for the past year for management of her diabetes. You have both been pleased about how well she has managed her sugars. She is here today for her yearly physical exam. She is married.