When touching's OK; when it's not

(istockphoto.com)

Recent reports that Dr. Melvin Levine, a prominent pediatrician and author, stands accused of molesting young male patients while working at Children's Hospital Boston has led to a collective gasp among the local healthcare community. While he denies the allegations, the report struck a chord of vulnerability for both doctors and patients.

We are all patients at one time or another, and there is no more vulnerable time than sitting naked in a cold exam room waiting for a near-stranger to hear all your secrets - whether physical or emotional. The revelations are then followed by a hands-on exam of bodily parts that prefer to be draped.

For children who are often scared, the whole process can feel like an assault. For young adults who view their every thought and move as top secret (except for the incessant blather online or on the cell to the chosen few), the indignity of visiting the doctor can be equally traumatic. Which is not to say, that adults welcome full disclosure either.

Let's face it, human sexuality is often the elephant in the room when doctors and patients interact. Or, I should say, perceived sexuality. What may seem like prurient interest from the patient's point of view may be just another breast exam, pelvic, or mole check in a busy afternoon. What can be deeply mortifying for a patient does not even register on the radar of a busy physician. After all, it is our job to look for wayward moles on hidden spots, check for hernias in an embarrassed young male, and to provide preventive care for sexually active young people.

The challenge is to provide thorough, sound care in a respectful, dignified setting. Many physicians when hearing of the accusations against Dr. Levine may think: "There but for the grace of God go I." Why do physicians feel vulnerable for such charges?

Physicians are taught in medical school to take a complete history and perform a thorough exam when diagnosing a medical problem, but a patient may wonder why her physician needs to listen to her heart when she is suffering from an infected toe. (An infection in one body part can lead to pericarditis, an infection of the heart.)

Children who are increasingly taught never to let strangers view their private parts are understandably reluctant to relinquish underwear when having an annual exam. Recently, a 4-year-old boy whom I have known since birth, spent his entire exam with me clutching his underpants, as if to say, "Don't even think of going there." But I had to: Any complete physical must include a genital exam. Not so long ago I discovered a large testicular mass on a 6-year-old boy that nobody in the family had noticed.

Most medical offices are set up to provide maximum privacy and dignity to a patient. Typically, if a male provider performs a pelvic exam, a chaperone is always present to provide comfort to the patient, but also to protect the physician. Increasingly, female doctors are now requiring chaperones for pelvic exams. With more and more sexual abuse charges surfacing in society, providers feel more vulnerable. And it is not just pelvic exams - what about listening to the heart? Breast exams? Genital exam?

Theoretically, all healthcare encounters should be witnessed by a third party to avoid potential "he-said-she-said" charges later. Providers are particularly at risk of unwarranted charges when a patient may be feeling more vulnerable, especially if they are mentally out of balance, such as a borderline personality.

The problem is that the doctor-patient bond is sacred and having a third person present can abort an important revelation, especially with a teenager. Some teens will share their sexual lives with parents, but most do not. A genital exam for a young adult male can be embarrassing enough without inviting another witness. In addition, the logistics of providing nursing chaperones for every interaction is not practical. Nurses are giving advice on the phone, drawing blood and giving immunizations, testing vision, weighing and measuring, placing patients in rooms, cleaning rooms and preparing them for the next patient, setting up referrals to specialists, preparing forms for school, and documenting most of the above in the electronic record.

Indeed, there are sexual deviants who surface in the medical world, but mostly, physicians are working hard to do a thorough job, while preserving patient dignity. And most patients, while feeling vulnerable, understand that what may be traumatic or embarrassing for them, is all in a day's work for the doctor.

Better communication between doctor and patient is always helpful; additionally, if patients feel vulnerable, they should feel comfortable requesting another person to be present during an exam, whether it be a nurse or a family member.

Dr. Victoria McEvoy is medical director of Mass. General West Medical Group and assistant professor of pediatrics at Harvard Medical School. She can be reached mcevoyvicky@gmail.com.

• Searched
• E-Mailed