Naked

There is an issue that most patients will experience and every family doctor or internist or surgeon will have contemplated as he or she has engaged in medical practice. Society has given the physician the right and duty to inspect and examine the human body by vision, hearing and touch. The issue will arise as to how the necessary examination can be performed skillfully and thoroughly and yet provide physical and emotional comfort for the patient. This procedure is what we try to teach medical students as they learn to perform physical examinations. Whereas, as mentors we can teach the techniques of inspection, palpation, percussion and auscultation and we can help the students understand general principles of professionalism and ethical behavior, more difficult for the student to learn is how to ensure a thorough and accurate exam while preserving the patient’s emotional comfort during the exam. In fact, there is also the issue of the student or physician’s emotional comfort during the exam. It all boils down to the matter of modesty by the patient and avoidance of any suggestion of voyeurism or prurient interest by the physician. Or even worse, sexual misconduct.

The problem in the American medical practice culture is that there are no strict and uniform rules regarding how to expose the patient’s body, whether or not to have a chaperone present with regard to genitalia, rectal or female breast examinations or other areas of the body and if present, who the chaperone should be.

This topic is discussed in the Perspective section of the current New England Journal of Medicine August 18, 2005 issue with the article “Naked” by Atui Gawande. M.D. Dr. Gawande is two years out of his surgical residency and has had the opportunity to talk with physicians who have practiced in other cultures around the world describing how the concern of modesty is handled in their country. He also discusses his own initial reaction about how he should examine a patient with strict attention to patient modesty such as avoiding the patient using a gown and simply or not so simply moving around the clothing. This action clearly became awkward and he resorted to gowned patients. Finally after noting the real professional problems of physician sexual misconduct but also false patient accusations due to misinterpretation, he concludes that explicit standards of what is a “normal” physical examination be set up or tightened so that both doctors and patients know and better doctor-patient relationships can be established.

I would be interested regarding what experiences you have had either as a patient or as a physician/nurse in the area of patient modesty and how the situation was managed. No names please. ..Maurice.

ADDENDUM (December 14, 2007): For more commentary on the same general topic, there are two addition thread sites, "Patient Modesty: A More Significant Issue?" and "Patient Modesty: Volume 2".

ADDITIONAL ADDENDUM: The photograph was taken by me on 8-21-2006 at J.P.Getty Villa Museum, Malibu, CA. is a Getty Bronze "Statue of a Victorious Youth" (Greek 325-300 B.C.)

ADDITIONAL ADDENDUM (May 10,2007): A link to the free pdf file of the NEJM article "Naked" was made available by one of the commentators. Use it to go directly to the article.

ADDITIONAL ADDENDUM (May 22 2008) WARNING:

THIS THREAD SEEMS TO BE OVERFILLED WITH COMMENTS AND YOUR FURTHER COMMENTS WILL NOT BE PUBLISHED. PLEASE GO TO "PATIENT MODESTY VOLUME 2" TO READ AND "PATIENT MODESTY VOLUME 3" TO BOTH READ AND WRITE NOW AND TO CONTINUE COMMENTS ON ISSUES WHICH HAVE APPEARED ON THIS THREAD. DO NOT TRY TO COMMENT ON THIS THREAD--IT WILL NOT BE PUBLISHED!!! HOWEVER, FOR THOSE WHO WANT TO READ ALL THE COMMENTS WHICH ARE MISSING ON THE FIRST PAGE, GO AHEAD AND CLICK "COMMENTS" ON THIS PAGE AND THEN CLICK ON "POST A COMMENT" ON THE NEXT PAGE AND FINALLY ON THE COMMENT WINDOW CLICK ON "NEWER" OR "NEWEST" OR "OLDER" AND SCROLL UP OR DOWN TO READ BUT DON'T WRITE!! ..Maurice.