Physical examinations: uncomfortable but still appropriate

Dec 14, 2016

A significant number of complaints against doctors allege that an examination was not conducted properly. Some allege inappropriate or unnecessary examinations and imply the doctor had an improper motive. Others allege assault or sexual assault and result in criminal charges.

Lifting a bra leads to a caution

A female patient attended a male GP complaining of symptoms consistent with a respiratory tract infection. The doctor did a thorough examination of the patient including listening to her chest and heart. The patient felt the way he auscultated her chest was inappropriate as he had lifted her bra without warning and deliberately rubbed the stethoscope bell against her nipple for sexual gratification. The patient had not expected a simple respiratory infection to require examination of the breast/nipple area.

Avant obtained a report indicating that auscultating the apex heart beat could bring the stethoscope bell close to the nipple. While this was supportive, the expert also indicated that clothing should only be removed by the patient, not the doctor. The doctor was cautioned by the Medical Board.

Fear of an allegation of inappropriate conduct sometimes deters a doctor from conducting a clinically indicated examination, which places them at risk of misdiagnosis. This fear should not interfere with good practice.

The clinical indication for a particular type of examination may be obvious to a doctor but not to the patient. This is particularly so for more vulnerable patients such as:

  • children
  • those requiring an intimate examination
  • the elderly
  • those for whom English is their second language.

The need for the examination should always be explained to the patient and they should be made aware that the examination can be stopped at any time. Their consent must also be obtained.

Providing this information may require others to be involved, such as substitute decision- makers, support persons and/or interpreters. This reflects the Medical Board’s Good Medical Practice: A Code of Conduct for Doctors in Australia, which states that practitioners should ensure “wherever practical, that arrangements are made to meet patients’ specific language, cultural and communication needs, and being aware of how these needs affect understanding”.

Communication

Good communication is key to avoiding misunderstandings and allegations arising from an examination. Prior to an examination, the patient’s confidence must be obtained by:

  • greeting new patients and introducing yourself (without being overly familiar)
  • allowing the patient to “tell their story” early in the history taking
  • listening to their story without interruption and without writing or typing
  • summarising their complaint(s) and their understanding of aetiology and issues arising from the complaint(s)
  • not dismissing their questions and/or concerns.

Issues raised by the patient that come from left of field should be explored by asking why the patient feels the issue is important.

The findings of any examination should also be explained to the patient and carefully documented.

A pain in the …

A patient with foot pain was diagnosed with plantar fasciitis. The doctor tried conservative measures with taping and oral anti-inflammatories, however the pain continued. The doctor injected Celestone and a local anaesthetic into the ankle/heel area on the left foot. The patient reported that this provided considerable relief of their symptoms.

When the patient developed similar pain in the right heel the doctor again injected Celestone and a local anaesthetic using a “no-touch” technique. The patient claimed the doctor did not wear gloves during the procedure and a band-aid applied during the procedure fell off before the patient left the treatment room and was not reapplied.

Subsequently, the patient developed severe pain in the foot and was eventually diagnosed with necrotising fasciitis and associated septicaemia with adult respiratory distress syndrome. A number of procedures were undertaken including application of a split skin graft.

The patient sought compensation of hundreds of thousands of dollars from the doctor and a hospital. Avant Law’s solicitors defended the doctor’s treatment by obtaining expert evidence that the method of injection was in accordance with accepted practice from an infectious diseases expert and an orthopaedic surgeon.

Hygiene

Hygiene is a significant issue for many patients. It’s important to wash your hands before and after each physical examination and regularly check that equipment has been sterilised correctly. If using a “no-touch” injection technique, which means gloves may not be necessary, explain this to the patient who may otherwise expect gloves to be worn. If doing a skin lesion check where the ability to feel the lesion is important for diagnosis, and therefore no gloves are worn, this should also be explained.

Chaperones

Many patients do not want a chaperone however all patients should be made aware of the option. The doctor can do this before the examination or it may be included in the practice information given to new patients.

For intimate examinations, particularly in the case of a very young adult, the doctor may decide that a chaperone should be present. This should be explained to the patient. If agreement cannot be reached, the examination should be delayed if the clinical urgency allows.

Chaperones may observe the examination or be in the room but not directly witness the examination. Let the patient determine this. Chaperones should be suitably qualified. View our video on the clinical, ethical and legal issues surrounding the use of chaperones or read our factsheet.

Respect and dignity

Respect for the patient’s dignity is essential. Patients should be able to undress in private and cover themselves with a robe, sheet or towel. It is not appropriate to ask sensitive questions during an examination. For example, asking a patient about their sex life during a vaginal examination will make a patient very uncomfortable.

Good practice for physical examinations

  • establish rapport through good communication
  • communicate what the examination will involve and why it is necessary
  • explain your actions as they happen to reassure the patient
  • be alert to indications of concern by a patient and address those concerns immediately
  • respect the patient’s dignity 
  • document discussions and examinations.

Learn more

For more advice on this topic contact our Medico-legal Advisory Service on 1800 128 268.
Complete our eLearning course ‘Gathering diagnostic information’ and obtain CPD points. You can also visit the Avant Learning Centre for case studies, articles, factsheets, eLearning courses, checklists and webinars.

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