Please remove your clothes

Everything at the refugee clinic is complicated.

Because most patients do not speak English and come from cultures vastly different from Canada's, the simplest tasks become difficult. Taking an obstetrical history, explaining an ultrasound procedure, defining anemia or recommending aspirin are challenging.

Then there's the physical exam.

My obstetrical patient today was due for her complete physical. After explaining the procedure, I handed her a gown. "Please take off all of your clothes," I said, miming the removal of my own shirt and pants, "and put on this gown."

The Swahili interpreter repeated my instructions, the patient smiled and nodded, and I pulled the curtain between us. I heard brief rustling; then all was still. I looked around the curtain to see the patient lying supine on the table, fully clothed.

"Please remove all of your clothes," I reiterated, again supplementing with gestures. "I need you to take off your shirt, pants, bra and underwear. Everything." She made an exclamation of understanding and I turned back to my desk to prepare the requisitions.

When I next pulled back the curtain, the patient was lying full-length on the table, pants on, sweater half over her head, with her bra bunched around her throat. This time I addressed the interpreter directly. "She didn't understand. She's still dressed. All of her clothes must come off."

Shortly thereafter I heard a burst of activity behind the curtain. I looked in to see the patient standing on the table. My six-foot pregnant patient was briskly disrobing while standing on a slender vinyl-covered exam table forty inches above the floor.

I decided it was safer not to intervene, and went back to assembling the speculum and swabs. A moment later she called out that she was ready.

And she was, lying on the table, naked, with the gown rolled up into a ball and tucked beneath her head.

Comments

[celeste allyn]

Maybe you could of offered her tea and made her feel more comfortable.
You have the best stories.

[slydi]

is it difficult for you to contain your giggle at that point? or do you just pretend you're coughing as you hide behind your cupped hand?

[Amy H.]

There is nothing left in life to shock you anymore, is there?

[mstpbound]

omg if that was a man i would diiiiiiie of embarassment. O.o'''

[Xavier Emmanuelle]

I couldn't help but laugh at that story. Too funny! I'm presuming you managed to cover her up somehow?

[JeanMac]

Well, at least the gown had a purpose:)

[Jody Jagt]

My heart actually aches for that woman. She must feel so lost in this country! Hopefully once she grasps the language she can look on this incident and see the humour, but I know I wouldn't like to be in her shoes!

[Mary Smith]

Hi Martina, this is Mark, actually. Great story. I can totally relate. I have the same kinds of misunderstandings in school with refugee kids or their parents, though usually the problems involve books, meetings, and assignments, rather than clothing removal. Hmm. So far.

[Chandra]

I'm at a bit of a loss to understand why this happened, when there was an interpreter there for you. How did he/she fail to get these pretty straight-forward instructions across to the patient???

[FreshMD]

Thanks for your comments.

@Chandra: Even English-speaking Canadians have surprised me with their interpretation of "Please remove your clothes and put on this gown." So it's to be expected that in my practice a new immigrant, who speaks no English and who's never had a complete physical, might be uncertain about the instructions. The interpreter might be using ambiguous terminology - maybe "undress" or "get ready for the doctor to examine you" instead of relaying my instructions in as exact a way as possible. Whatever the reasons, scenarios like the one above have played out in my office on many occasions.

@slydi & Jody Jagt: Yes, a complete physical can be an awkward enough experience without issues around disrobing. Interestingly, most of my patients are not easily embarrassed. Sometimes the patient will chuckle with me over the miscommunication, and humour is a great way to establish rapport.

[kitt]

I can empathize with the patient.

http://kittsfulbright.blogspot.com/2008/12/how-its-different-doctor.html

[S]

I just found your blog.

Just wanted to say that the complete disrobing is not really standard worldwide. The idea of the paper gown and all that was invented by some efficiency expert in the US who figured out that having patients naked and waiting is "faster" for the doctor. But there's no real reason for it.

In many other countries, my experience has been different. We rarely disrobe patients. Most places, I've never even seen a paper gown - they use sheets if needed. They go onto the table dressed, pull up a shirt for the cardiac exam. You can stick a hand and stethoscope underneath just fine. Then they can pull it back down and just pull pants down a little for the abdomen...I've never put a patient naked for a pelvic...they take off their bottom part, or pull up the dress or skirt, and then a sheet over their knees or waist.

Depending on where you are, a thyroid/neck can be examined without fully removing a hijab. A bra only needs to be removed for a breast exam, it can be moved around for anything else. And the difference in how it feels to be lying on a table in your bra versus stripped totally is immense.

So that's my practice now too in the Western world. Is saving a few seconds really worth the discomfort of a patient being totally naked?

When patients come in, first we talk - I never do the thing where they disrobe while waiting for me. Then, since most of the time in primary care I'm doing just a focused exam anyway, I ask them to lie down on the table, dressed, sometimes take off shoes and socks to check feet. But most patients expect to be naked. They jump up on the table and look kind of confused, "Should I take off something?" "Let's not get carried away," I usually answer, and smile.

The one caveat is that once you get used to this, you have to sometimes remember to insist that they do take off an entire article of clothing to see well, which seems awkward after not doing it for so long.

I think Atul Gawande wrote an essay about different customs about this around the world.

[wendy]

This made me laugh! My hubby (who is a doctor, but no longer practices) used to tell patients who came up to him in the grocery store, library, bank (virtually any public place) that if they wanted him to look at something (even a knee or elbow) they'd have to undress. This stopped the questions: "hey doc, could ya just take a look at my knee?"