Free Better by Atul Gawande Page B

examination, there is a two-inch circle cut in the screen. "Tell her to come closer," the doctor says. The boy does. She brings her mouth to the opening, and through it he looks inside. "Have her bring her eye to the hole," he says. And so the exam goes. Such, apparently, can be the demands of decency.
    When I started in my surgical practice, I was not at all clear what my etiquette of examination should be. There are no clear standards in the United States, expectations are murky, and the topic can be fraught with hazards. Physical examination is deeply intimate, and the way a doctor deals with the naked body--particularly when the doctor is male and the patient female--inevitably raises questions of propriety and trust.
    No one seems to have discovered the ideal approach. An Iraqi surgeon told me about the customs of physical examination in his home country. He said he feels no hesitation about examining female patients completely when necessary, but because a doctor and a patient of opposite sex cannot be alone together without eyebrows being raised, a family member will always accompany them for the exam. Women do not remove their clothes or change into a gown. Instead, only a small portion of the body is uncovered at any one time. A nurse, he said, is rarely asked to chaperone: if the doctor is female, it is not necessary, and if male, the family is there to ensure that nothing unseemly occurs.
    In Caracas, according to a Venezuelan doctor I met, female patients virtually always have a chaperone for a breast or pelvic exam, whether the physician is male or female. "Thatway there are no mixed messages," the doctor said. The chaperone, however, must be a medical professional. So the family is sent out of the examination room, and a female nurse brought in. If a chaperone is unavailable or the patient refuses to allow one, the exam is not done.
    A Ukrainian internist from Kiev told me that she has not heard of doctors there using a chaperone. I had to explain to her what a chaperone was. If a family member is present at an office visit, she said, he or she will be asked to leave. Both patient and doctor wear their uniforms--the patient a white examining gown, the doctor a white coat. Last names are always used. There is no effort at informality to muddy the occasion. These practices, she believes, are enough to solidify trust and preclude misinterpretation of the conduct of care.
    A doctor, it appears, has a range of options.
    In October 2003, I posted my clinic hours, and soon my first patients arrived to see me. For the first time, I realized, I was genuinely alone with patients. No attending physician supervising in the room or getting ready to come in; no bustle of emergency room personnel on the other side of a curtain. Just a patient and me. We'd sit down. We'd talk. I'd ask about whatever had occasioned the visit, about past medical problems, medications, the family and social history. Then the time would come to have a look.
    There were, I will admit, some inelegant moments. I had an instinctive aversion to examination gowns. At our clinic they are made of either thin, ill-fitting cloth or thin, ill-fitting paper. They seem designed to leave patients exposed and cold. I decided to examine my patients while they were in their street clothes, for the sake of dignity. If a patient with gallstoneswore a shirt she could untuck for the abdominal exam, this worked fine. But then I'd encounter a patient in tights and a dress, and the next thing I knew, I had her dress bunched up around her neck, her tights around her knees, and both of us wondering what the hell was going on. An exam for a breast lump one could manage, in theory: the woman could unhook her brassiere and lift or unbutton her shirt. But in practice, it just seemed weird. Even checking pulses could be a problem. Pant legs could not be pushed up high enough to check a femoral pulse. (The femoral artery is felt at the crease of the groin.) Try pulling them down