2.2.2: Guidelines for Avoiding Misunderstandings During Patient Encounters and Physical Examinations

It is the position of the Board that respect, empathy, and sensitivity to the vulnerability of patients are needed at all times during a patient encounter in order to avoid misunderstandings that could lead to charges of boundary violation or sexual misconduct against licensees. The Board offers the following guidelines to assist licensees in reducing the possibility of such misunderstandings.

• Licensees should recognize that misunderstandings regarding boundaries may occur at any time during a patient encounter, but particularly during disclosure of private information by the patient about symptoms, prior personal experiences, or during the physical examination. The licensee should maintain a professional demeanor at all times. While some licensees have adopted a more informal approach to patient interactions, such as use of first names for both patients and the licensee, this may blur boundaries and result in later misunderstandings.

• Sensitivity to patient modesty and dignity must be maintained at all times. The patient should be assured of adequate privacy and should never be asked to disrobe in the presence of the licensee. Examining rooms should be well maintained and equipped with appropriate furniture and supplies for examination and treatment. Gowns, sheets, and/or other appropriate apparel should be made available to the patient.

• Regardless of the patient’s gender, a third-party chaperone, possibly a staff member, should be readily available at all times during a physical examination, and it is strongly advised that a third party be present when the licensee performs an examination of the breasts, genitalia, or rectum. It is the licensee’s responsibility to have a staff member available at any point during the examination. If no chaperone is available, the patient should be clearly advised of what will occur during the examination and provide verbal informed consent for an unchaperoned examination.

• The licensee should individualize the approach to physical examinations so that each patient’s sense of vulnerability, apprehension, fear, and embarrassment are diminished to the extent possible. An explanation of the necessity of a complete physical examination, the components of that examination, and the purpose of disrobing may be necessary in order to minimize the patient’s apprehension.

• The licensee and staff should exercise the same degree of professionalism and care when performing diagnostic procedures (e.g., electrocardiograms, electromyograms, endoscopic procedures, and radiological studies, etc.), as well as during surgical procedures and postsurgical follow-up examinations when the patient is in varying stages of consciousness.

• Sexual impropriety by the licensee may include behavior, gestures, comments, or expressions that are seductive, sexually suggestive, disrespectful of patient privacy, or sexually demeaning to a patient, and may include, but are not limited to:

- Neglecting to employ disrobing or draping practices that respect patient privacy or deliberately watching a patient dress or undress.

- Subjecting a patient to an intimate examination in the presence of students or other persons without the patient’s consent.

- Examination or touching of genitals/genital mucosal areas without the use of gloves.

- Unprofessional comments made at any time during the encounter about or to the patient, including making sexual comments about a patient’s appearance, body, or clothing or offering demeaning observations about the patient or others.

- Using a licensee-patient encounter to solicit a date or romantic relationship.

- Conversations or comments regarding the sexual problems, preferences, or fantasies of the licensee.

- Performing an examination without clinical justification or without explaining to the patient the need for such examination.

- Requesting details of the patient’s sexual history or sexual preferences when not clinically indicated.

• The licensee should also be alert for suggestive or flirtatious behavior or mannerisms on the part of the patient and should not permit a compromising situation to develop.