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The NEW ENGLAND JOURNAL of MEDICINE
Perspective august 18, 2005
Naked
Atul Gawande, M.D., M.P.H.
T here is an exquisite and fascinating scene in
Kandahar, a movie set in Afghanistan under the
Taliban regime, in which a male physician is asked
proach. A surgical colleague who
practices in Iraq told me about
the customs of physical exami-
nation there. He said he feels no
to examine a female patient. They are separated by hesitation about examining fe-
male patients completely when
an opaque screen. Behind it, the her bring her eye to the hole,” necessary, but because a doctor
woman is covered from head to he says. And so the exam goes. and a patient of opposite sex can-
toe by her burka. The two do not Such, apparently, can be the de- not be alone together without
talk directly to each other. The mands of decency. eyebrows being raised, a family
patient’s young son serves as the When I started my surgical member will always accompany
go-between. She has a stomach- practice two years ago, I was not them for the exam. Women do
ache, he says. at all clear about what my own not remove their clothes or change
“Does she throw up her food?” etiquette of examination should into a gown for the exam, and
the doctor asks. be. Expectations are murky; we only a small portion of the body
“Do you throw up your food?” have no clear standards in the is uncovered at any one time. A
the boy asks. United States; and the topic can nurse, he said, is rarely asked to
“No,” the woman says, per- be fraught with hazards. Physi- chaperone: if the doctor is female,
fectly audibly, but the doctor waits cal examination is deeply inti- it is not necessary, and if male,
as if he has not heard. mate, and the way a doctor deals the family is there to ensure that
“No,” the boy tells him. with the naked body — particu- nothing unseemly occurs.
For the exam, the doctor has larly when the doctor is male In Caracas, according to a
cut a two-inch circle in the screen. and the patient female — inevi- Venezuelan doctor I met, female
“Tell her to come closer,” he says. tably raises questions of propri- patients virtually always have a
The boy does. She brings her ety and trust. chaperone for a breast or pelvic
mouth to the opening, and No one anywhere seems to exam, whether the physician is
through it he looks inside. “Have have discovered the ideal ap- male or female. “That way there
n engl j med 353;7 www.nejm.org august 18, 2005 645
PE R S PE C T IV E naked
are no mixed messages,” the doc- a shirt she could untuck for the vic and rectal exams — “any-
tor said. The chaperone, however, abdominal exam, this worked thing below the waist” — but
must be a medical professional. fine. But then I’d encounter a only rarely for breast exams. Oth-
So the family is sent out of the patient in stockings and a dress, ers have a chaperone for breast
examination room, and a nurse and the next thing I knew, I had and pelvic exams but not for rec-
brought in. If a chaperone is un- her dress bunched up around her tal exams. Some did not have a
available or has refused to par- head, her tights around her knees, chaperone at all. Indeed, an ob-
ticipate, the exam is not done. stetrician–gynecologist estimated
A Ukrainian internist told me that about half the male physi-
that she has not heard of doc- cians in his department do not
tors in Kiev using a chaperone. routinely use a chaperone. He
If a family member is present, himself detests the word “chap-
he or she will be asked to leave. erone” because it implies that
Both patient and doctor wear mistrust is warranted, but he
their uniforms — the patient a offers to bring in an “assistant”
white examining gown, the doc- for pelvic and breast exams. Few
tor a white coat. Last names are of his patients, however, find the
always used. There is no effort presence of the assistant neces-
at informality to muddy the occa- sary after the first exam, he said.
sion. This practice, she believes, If the patient prefers to have her
is enough to solidify trust and sister, boyfriend, or mother stay
preclude misinterpretation of the for the exam, he does not object
conduct of care. — but he is under no illusion
A doctor, it appears, has a and both of us wondering what that a family chaperone offers
range of options. the hell was going on. An exam protection against an accusation
In 2003, I set up my clinic for a breast lump one could man- of misconduct. Instead, he relies
hours, and soon people arrived to age, in theory: the woman could on his reading of a patient to
see me. I was, I realized, for the unhook her brassiere and lift or determine whether bringing in a
first time genuinely alone with unbutton her shirt. But in prac- nurse–witness would be wise.
patients. No attending physician tice, it just seemed weird. Even One of our residents, who was
in the room or getting ready to checking pulses could be a prob- trained partly in London, said he
come in; no bustle of emergency lem. Pant legs could not be pushed found the selectivity here strange.
room personnel on the other side up high enough. Try pulling “In Britain, I would never exam-
of a curtain. Just a patient and them down over shoes, however, ine a woman’s abdomen without
me. We’d sit down. We’d talk. and . . . forget it. I finally began a nurse present. But in the emer-
I’d ask about whatever had occa- to have patients change into the gency room here, when I asked
sioned the visit, about past med- damn gowns. (I haven’t, however, to have a nurse come in when I
ical problems, medications, the asked men to do so nearly as of- needed to do a rectal exam or
family and social history. Then ten as women.) check groin nodes on a woman,
the time would come to have As for having a chaperone they thought I was crazy. ‘Just
a look. present with female patients, I go in there and do it!’ they said.”
There were, I will admit, hadn’t settled on a firm policy. In England, he said, “if you need
some awkward moments. I had I found that I always asked a to do a breast or rectal exam or
an instinctive aversion to exami- medical assistant to come in for even check femoral pulses, espe-
nation gowns. At our clinic they pelvic exams and generally didn’t cially on a young woman, you
are made of either thin, ill-fitting for breast exams. I was com- would be either foolish or stu-
cloth or thin, ill-fitting paper. pletely inconsistent about rectal pid to do it without a chaper-
They seem designed to leave pa- exams. one. It doesn’t take much — just
tients exposed and cold. I decid- I surveyed my colleagues about one patient complaining, ‘I came
ed to examine my patients while what they do and received a va- in with a foot pain and the doc-
they were in their street clothes. riety of answers. Many said they tor started diving around my
If a patient with gallstones wore bring in a chaperone for all pel- groin,’ and you could be suspend-
646 n engl j med 353;7 www.nejm.org august 18, 2005
PE R S PE C TI V E naked
ed for a sexual-harassment inves- The difficulty for those of us course with patients during pel-
tigation.” who do not behave badly is that vic exams. The vast majority of
Britain’s standards are strin- medical exams remain inherently cases involved male physicians
gent: the General Medical Coun- ambiguous. Any patient can be and female patients, and virtu-
cil, the Royal College of Physi- led to wonder: Did the doctor ally all occurred without a chap-
cians, and the Royal College of really need to touch me there? erone present.5 About one third
Obstetricians and Gynaecologists Even when doctors simply in- of cases studied in one state in-
specify that a chaperone must be quire about patients’ sexual his- volved actual sexual intercourse
offered to all patients who under- tory, can anyone be certain of the with patients; two thirds involved
go an “intimate exam” (i.e., in- intent? The fact that all medical sexual impropriety or inappro-
volving the breasts, genitalia, or professionals have blushed or priate touching short of sexual
rectum), irrespective of the sex found their thoughts straying contact. Another goal might be
of the patient or of the doctor.1,2 during a patient visit reveals the to reduce false accusations aris-
A chaperone must be present potential for impropriety in any ing from misinterpretation.
when a male physician performs encounter. Nonetheless, eliminating mis-
an intimate exam of a female The tone of an office visit can conduct and accusations would
patient. The chaperone should be turn on a single word, a joke, a be the wrong aim to guide med-
a female member of the medical comment about a tattoo in an un- ical care. The trouble is not that
team, and her name should be expected place. One surgeon told such acts are rare (though the
recorded in the notes. If the pa- me of a young patient who ex- statistics suggest they are), nor
tient refuses a chaperone and the pressed concern about a lump in that total prevention — zero tol-
examination is not urgent, it her “boob.” But when he used the erance — is impossible. It is
should be deferred until it can be same word in response, she be- that, at some point, the measures
performed by a female physician. came extremely uncomfortable required to achieve total preven-
In the United States, we have and later made a complaint. An- tion will approach the Taliban-
no such guidelines. As a result, other woman I know left her gy- esque and harm care of patients.
our patients have little idea of necologist after he made an off- Embracing more explicit stan-
what to expect from us. To be hand, probably inadvertent, but dards for medical encounters,
sure, some minimal standards admiring comment about her tan however, might actually improve
have been established. The Fed- lines during a pelvic exam. relationships with patients —
eration of State Medical Boards The examination itself — the and that does stand as a worthy
has spelled out that touching a how and where of the touching goal. The new informality of
patient’s breasts or genitals for a — is, of course, the most poten- medicine — with white coats dis-
purpose other than medical care tially dicey territory. If a patient appearing, and patient and doc-
is a disciplinable offense. So are even begins to doubt the propri- tor sometimes on a first-name
oral contact with a patient, en- ety of what a doctor is doing, basis — has blurred boundaries
couraging a patient to masturbate something is not right. So what that once guided us. If physicians
in one’s presence, and providing then should our customs be? are unsure about what is appro-
services in exchange for sexual There are many reasons to priate behavior for themselves,
favors. Sexual impropriety — consider setting tighter, more is it any surprise that patients
which involves no touching but uniform professional standards. are, too? Or that misinterpreta-
is no less proscribed — includes One is to protect patients from tion can occur? We have jetti-
asking a patient for a date, criti- harm. About 4 percent of the soned our old customs but have
cizing a patient’s sexual orienta- disciplinary orders that state not bothered to replace them.
tion, making sexual comments medical boards issue against phy- My father, a urologist, has
about the patient’s body or cloth- sicians are for sex-related of- thought carefully about how to
ing, and initiating discussion of fenses. One of every 200 physi- avert such uncertainties. From
one’s own sexual experiences or cians is disciplined for sexual the start, he felt the fragility of
fantasies.3 I can’t say anyone misconduct with patients some- his standing as an outsider, an
taught me these boundaries in time during his or her career.4 Indian immigrant practicing in
medical school, but I would like Some of these cases involve such a rural Ohio town. In the absence
to think that no one needed to. outrageous acts as having inter- of guidelines to reassure patients
n engl j med 353;7 www.nejm.org august 18, 2005 647
PE R S PE C T IV E naked
that what he does as a urologist patients, and they trust him com- tell when you’ve seen a thousand
is routine, he has made pains- pletely. I find, however, that some naked patients and when you
taking efforts to avoid question. of his practices do not seem quite haven’t. I now know that’s true.
The process begins before the right for me. My patients are as But I have also come to recognize
exam. He always arrives in a tie likely to have problems above the that no patient has seen a thou-
and white coat. He is courtly. Al- waist as below, and having a chap- sand doctors. They therefore have
though he often knows patients erone present for a routine ab- little idea, coming to a doctor’s
socially and doesn’t hesitate to dominal exam or a check of groin office, of what is “normal” and
speak with them about personal pulses feels to me absurd. I don’t what is not. This we can change.
matters (the subjects can range don gloves for nongenital exams.
Dr. Gawande is a general and endocrine sur-
from impotence to sexual affairs), Nonetheless, I have tried to em- geon at Brigham and Women’s Hospital and
he keeps his language strictly ulate the spirit of my father’s vis- an assistant professor at Harvard Medical
medical. If a female patient must its — the decorum in language School and at the Harvard School of Public
Health, Boston.
put on a gown, he steps out while and attire, the respect for mod-
she undresses. He makes a point esty, the precision of examination. 1. Intimate examinations. London: General
of explaining what he is going As I think further about his ex- Medical Council Standards Committee, De-
to do during the examination ample, it has also led me to make cember 2001.
2. Gynaecological examinations: guidelines
and why. If the patient lies down some changes: I now uniformly for specialist practice. London: Royal College
and needs further unzipping or use an assistant not just for pelvic of Obstetricians and Gynaecologists, July
unbuttoning, he is careful not to exams but also for rectal exams 2002.
3. Ad Hoc Committee on Physician Impair-
help. He wears gloves even for of female patients and as patients ment. Report on sexual boundary issues.
abdominal examinations. If the desire, for breast exams as well. Dallas: Federation of State Medical Boards
patient is female or under 18 years For the comfort and reassurance of the United States, April 1996.
4. Dehlendorf CE, Wolfe SM. Physicians dis-
of age, then he brings in a nurse of patients, these seem to be rea- ciplined for sex-related offenses. JAMA 1998;
as a chaperone, whether the exam sonable customs, even expecta- 279:1883-8.
is “intimate” or not. tions, for more of us to accept. 5. Enbom JA, Thomas CD. Evaluation of
sexual misconduct complaints: the Oregon
His approach has succeeded. A professor once told my med- Board of Medical Examiners, 1991 to 1995.
I grew up knowing many of his ical school class that patients can Am J Obstet Gynecol 1997;176:1340-8.
Medical Marijuana and the Supreme Court
Susan Okie, M.D.
A ngel McClary Raich, a Califor-
nia woman at the center of
the recent Supreme Court case on
it relieves her chronic pain and
boosts her appetite, preventing her
from becoming emaciated because
sional meetings in Washington
prevented her from medicating
herself with cannabis as regu-
medical marijuana, hasn’t changed of a mysterious wasting syndrome. larly as she needed to. “My body
her treatment regimen since the Raich and her doctor maintain was shutting down on me,” she
Court ruled in June that patients that without access to the eight said in an interview from her
who take the drug in states where or nine pounds of privately grown Oakland home last month. “I’m
its medicinal use is legal are not cannabis that she consumes each scared of my health failing. I’m
shielded from federal prosecution. year, she would die. scared of the federal government
A thin woman with long, dark Although Raich has embraced coming in and doing more harm.
hair and an intense gaze, Raich a public role advocating the me- [Recently,] the city of Oakland
takes marijuana, or cannabis as dicinal use of marijuana, she says warned there were going to be
she prefers to call it, about every that her health suffered during some raids” on marijuana dispen-
two waking hours — by smoking the hectic days following the an- saries. “We’re all just waiting.
it, by inhaling it as a vapor, by eat- nouncement of the Court’s deci- Sitting on the frontline is ex-
ing it in foods, or by applying it sion, when a whirlwind schedule tremely stressful.”
topically as a balm. She says that of press conferences and congres- In the Supreme Court case
648 n engl j med 353;7 www.nejm.org august 18, 2005
