Atul Gawande Perspective

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					The   NEW ENGLAND JOURNAL                                                            of   MEDICINE

                                                                       Perspective        august 18, 2005

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   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   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   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   august 18, 2005

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