It’s among the most vulnerable, yet often routine situations a person faces: a physical exam with a clinician.
In most instances, a clinician’s professionalism and respect for boundaries — instilled through years of education, licensing, and medical practice — earns the patient’s trust, and care is delivered without incident.
However, these circumstances at times give rise to patient complaints against clinicians who fail to maintain professional boundaries. These incidents can range from inappropriate remarks to unnecessary physical contact to allegations of assault.
High-profile scandals in recent years of repeated sexual assault committed by clinicians against patients have attracted news headlines. But clinicians and their medical organizations should understand that most incidents involve subtler behaviors that lack malicious intent but cross boundaries. That can include miscommunication by the clinician, failure to respect the patient’s privacy, inappropriate attempts at humor, failure to offer a chaperone, or carrying out procedures without proper explanation.
Patients who don’t feel safe or respected during exams can lodge complaints that may lead to litigation, licensing issues, and reputational risk for clinicians and their organizations. These risks often stem from a lack of clear organizational policies, training, and oversight, as well as a clinician’s failure to observe boundaries that can leave patients vulnerable during an exam.
Conversely, clinicians who observe professional boundaries and follow best practices, along with organizations that reinforce these practices, can help patients feel safe, respected, and heard during exams.
Setting the stage for a respectful exam
Clinicians should always recognize that patients may feel anxious about a forthcoming exam. This could be due to the reason for their visit, the nature of the exam, or possibly a history of trauma.
And patients should know, before and during the visit, that they control the exam and can pause, adjust, or end it at any time. Patients should feel comfortable setting their own boundaries and knowing that speaking up will not affect their care.
Clinicians can and should set an appropriate tone and boundaries at the beginning of an exam. Before a clinician touches a patient, they should introduce themselves and their role, as well as the role of any other staff in the room.
They should explain the purpose of the exam, including a straightforward description of what the clinician will do, why it is needed, where on the patient’s body the clinician will touch, and the expected duration of the exam.
Respecting privacy and maintaining a professional touch
Clinicians and their staff should also provide and respect a patient’s privacy as they undress and dress for an exam, if applicable.
Once the exam's purpose is made clear, the clinician should ask for permission to begin. Throughout an exam, a clinician should:
Expose only the areas of the patient’s body necessary for the specific portion of the exam. They should use only clinically indicated touches consistent with the exam's purpose and re-drape the area promptly after each portion of the exam.
Maintain focus and awareness and perform the exam without lingering contact, unnecessary proximity, or touching outside the exam area.
Watch for patient reactions or other nonverbal clues. Maintain a calm, straightforward tone of voice and keep the conversation with the patient within the confines of the exam.
Avoid making any comments that a patient may misinterpret. Lighthearted comments or attempts at humor can strike a patient much differently than intended.
Narrating care and seeking consent throughout
The clinician should always explain transitions between exam components and obtain consent again at each stage. Clinicians should never assume that permission at the outset applies to each subsequent stage of the exam.
Examples of narrating care and seeking consent include:
“I’m going to examine your abdomen. I’ll press in a few areas to check for tenderness. Is it okay to continue?”
“You may feel pressure here. Please tell me if it’s uncomfortable or if you want me to stop.”
Clinicians and their staff should help patients understand and feel comfortable speaking up about any discomfort they experience during the exam. Any expression of discomfort should prompt the clinician to pause immediately, respond supportively, acknowledge the concern, and offer the patient the option to adjust or stop the exam if requested.
By narrating care, patients and clinicians both benefit from transparency, permission, and the knowledge that the patient ultimately controls the exam process.
Chaperones as a boundary tool
Chaperones, members of an organization’s staff who accompany patients for support and as a witness to the exam, fulfill an active and important role in a safe and respectful exam. They are not merely a body in the room during an exam, but rather a presence that can help offer a patient comfort, help maintain boundaries, and respect their dignity.
Healthcare organizations should adopt policies that clearly identify the types of exams for which chaperones should be offered to patients. Organizations may also require chaperones for certain types of exams, either through their own policy decisions or as a condition set by their professional liability carrier.
In making the offer, the organization should inform the patient, respectfully, that chaperones will be present throughout the exam and positioned appropriately. The chaperone will support the patient and document the exam. And the chaperone will maintain professional standards of privacy and confidentiality, just as the clinician would.
If a patient refuses the organization’s offer to provide a chaperone, the explanation of the chaperone’s role and the patient’s decision to decline the opportunity should be documented clearly. If the patient refuses a chaperone for an exam for which the organization has made a chaperone's presence a requirement, the organization should document it clearly as an “informed refusal” and may decline to proceed with the exam. That refusal should be clearly documented, as well.
Trauma-informed considerations
Clinicians should always keep in mind the possibility that a patient has experienced a past trauma, or traumas, that may affect their response to physical exams.
This possibility underscores the need for clinicians to ask for permission before repositioning or moving clothing, frequently checking in with the patient, slowing the pace of the exam, and offering choices and alternatives as needed. What may seem like a small adjustment to the exam process to the clinician can go a long way toward reducing the patient’s stress and discomfort.
Patients who have experienced past trauma may benefit from having a support person present, if it’s appropriate and in accordance with organizational policies. The importance of documentation Clinicians and their organizations should maintain clear, straightforward, and plain-language documentation of the exam that focuses solely on clinically relevant facts.
Those include:
The reason and indications for the exam, including its duration and potential risks.
Any discussions about consent.
Whether a chaperone was offered, accepted, or declined.
The patient’s tolerance to the exam and any modifications to the exam procedures in response to patient requests or discomfort.
These notes should not be written defensively and should avoid overly explanatory passages.
Consistent, accurate documentation supports an organizational culture of safety for both patients and clinicians.
Conclusion
Medical professional boundaries, enforced by state licensing boards, exist to protect both the clinician and the patient. When consistently applied, they lead to respectful and ethically sound exam practices. Organization policies, supervision, and ongoing training reinforce those boundaries. Conversely, neglecting those practices puts everyone involved in danger.
Clear communication with a patient can help them feel more at ease and lead to their physical and psychological comfort. Consent and narrated care are not one-time events, but rather ongoing and consistent processes. Chaperones, if used in keeping with organizational policies, and documentation help keep patients and clinicians safe.
These practices all promote respectful exams, patient safety, a culture of trust, professionalism, and risk reduction.