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  One of our residents, who was trained partly in London, said he found the selectivity here strange. "In Britain, I would never examine a woman's abdomen without a nurse present. But in the emergency room here, when I asked to have a nurse come in when I needed to do a rectal exam or check groin nodes on a woman, they thought I was crazy. 'Just go in there and do it!' they said." In England, he said, "if you need to do a breast or rectal exam or even check femoral pulses, especially on a young woman, you would be either foolish or stupid to do it without a chaperone. It doesn't take much--just one patient complaining, 'I came in with a foot pain and the doctor started diving around my groin,' and you could be suspended for a sexual harassment investigation."

  Britain's standards are stringent: the General Medical Council, the Royal College of Physicians, and the Royal College of Obstetricians and Gynaecologists specify that a chaperone of the appropriate gender must be offered to all patients who undergo an "intimate examination" (that is, involving the breasts, genitalia, or rectum), irrespective of the gender of the patient or of the doctor. A chaperone must be present when a male physician performs an intimate examination of a female patient. The chaperone should be a female member of the medical team, and her name should be recorded in the notes. If the patient refuses a chaperone and the examination is not urgent, it is supposed to be deferred until it can be performed by a female physician.

  In the United States, where we have no such guidelines, our patients have little idea of what to expect from us. To be sure, some minimal standards have been established. The Federation of State Medical Boards has spelled out that touching a patient's breasts or genitals for a purpose other than medical care is a sexual violation and a disciplinable offense. So are oral contact with a patient, encouraging a patient to masturbate in one's presence, and providing services in exchange for sexual favors. Sexual impropriety--which involves no touching but is no less proscribed--includes asking a patient for a date, criticizing a patient's sexual orientation, making sexual comments about the patient's body or clothing, and initiating discussion of one's own sexual experiences or fantasies. I can't say anyone taught me these boundaries in medical school, but I would like to think that no one needed to teach them.

  The difficulty for doctors who behave properly is that medical exams remain inherently ambiguous. Any patient can be led to wonder: Did the doctor really need to touch me there? And when doctors simply inquire about patients' sexual history, can anyone be certain of the intent? The fact that all medical professionals have blushed or found their thoughts straying in unwanted directions during a patient visit reveals the potential for impropriety.

  The tone of an office visit can turn on a single word, a joke, a comment about a tattoo in an unexpected place. One surgeon told me of a young patient who expressed concern about a lump in her "boob." But when he used the same word in response, she became extremely uncomfortable and later made a complaint. A woman I know left her gynecologist after he let slip an offhand admiring comment about her tan lines during a pelvic exam.

  The examination itself--the how and where of the touching--is, of course, the most potentially dicey territory. If a patient even begins to doubt the propriety of what a doctor is doing, something must not be right. So what then should our customs be?

  There are many reasons to consider setting tighter, more uniform professional standards. One is to protect patients from harm. About 4 percent of the disciplinary orders that state medical boards issue against physicians are for sex-related offenses. One of every two hundred physicians is disciplined for sexual misconduct with patients sometime during his or her career. Some of these cases have involved such outrageous acts as having intercourse with patients during pelvic exams. The vast majority of cases involved male physicians and female patients, and virtually all occurred without a chaperone present. In one state, about a third of cases involved dating patients or sexual touching of them; two-thirds involved sexual impropriety or inappropriate touching short of sexual contact.

  Clearer standards could also reduce false accusations against physicians. Chaperones in particular provide physicians with a stronger defense when such accusations are made. Inappropriate patient behavior might be averted, too. A 1994 study found that 72 percent of female medical students and 29 percent of male medical students experienced at least one instance of patient-initiated sexual behavior. Twelve percent of the females were sexually touched or grabbed by patients.

  Yet, all this said, eliminating misconduct and accusations seems like the wrong priority to drive how doctors proceed when examining patients' bodies. The trouble is not that problems are rare (though the statistics suggest they are) or that total prevention of impropriety--zero tolerance--is impossible. It is that the measures required to achieve total prevention inevitably approach the Talibanesque and risk harming patients by discouraging complete and thorough examinations.

  Instead, the most important reason to consider tightening standards of medical protocol is simply to improve trust and understanding between patients and doctors. The new informality of medicine--with white coats disappearing and patient and doctor sometimes on a first-name basis--has blurred boundaries that once guided us. If physicians are unsure about what the etiquette of the examination room should be, is it any surprise that patients are, too? Or that misinterpretations occur? We have jettisoned our old customs but we have not managed to replace them.

  My father, a urologist, has thought carefully about how to avert such uncertainties. From the start, he told me, he felt the fragility of his standing as an outsider, an Indian immigrant practicing in our small southern Ohio town. In the absence of guidelines to reassure patients that what he does as a urologist is routine, he made painstaking efforts to avoid any question.

  The process begins before the examination. He always arrives in a tie and white coat. He is courtly. Although he often knows patients socially and doesn't hesitate to speak with them about private matters (the subjects can range from impotence to sexual affairs), he keeps his language strictly medical. If a female patient must put on a gown, he steps out while she undresses. He makes a point of explaining what he is going to do during the examination and why. If the patient lies down and needs further unzipping or unbuttoning, he is careful not to help. He wears gloves even for abdominal examinations. If the patient is female or under eighteen years of age, he brings in a female nurse as a chaperone, whether the examination is "intimate" or not.

  His approach works. He has a busy practice. There have been no unseemly rumors. I grew up knowing many of his patients, and they seemed to trust him completely.

  I find, however, that some of his practices are not quite right for me. My patients are as likely to have problems above the waist as below, and having a chaperone present for a routine abdominal exam or an examination of enlarged lymph nodes under an arm seems absurd to me. I don't don gloves for nongenital exams, either. Nonetheless, I have tried to emulate the spirit of my father's visits--the decorum in language and attire, the respect for modesty, the precision of examination. And as I thought further about his example, I made changes: I now routinely bring in a female assistant not just for pelvic exams but also for female breast and rectal exams. "If it's all right, I'll go get Janice," I say. "She can be our chaperone."

  IT IS UNSETTLING to find how little it takes to defeat success in medicine. You come as a professional equipped with expertise and technology. You do not imagine that a mere matter of etiquette could foil you. But the social dimension turns out to be as essential as the scientific--matters of how casual you should be, how formal, how reticent, how forthright. Also: how apologetic, how self-confident, how money-minded. In this work against sickness, we begin not with genetic or cellular interactions, but with human ones. They are what make medicine so complex and fascinating. How each interaction is negotiated can determine whether a doctor is trusted, whether a patient is heard, whether the right diagnosis is made, the right treatment given. But in this realm there are no perfec
t formulas.

  Consider my chaperone solution, for example. A Manhattan friend in her thirties told me about seeing a dermatologist because of a mole she was worried about. The doctor was in his sixties and perfectly professional. When it came time for him to examine the mole and to check whether she had any others under her threadbare examination gown, he brought in a chaperone. This was, in theory, for her comfort and reassurance. But the chaperone--a female aide who stood watching as the dermatologist inspected my friend's body--only made her feel more conspicuously on display.

  "It was awkward," my friend told me. "The very idea of a chaperone seems to shout: This is a highly charged situation, and in order to avoid possible he-said, she-said litigation, this nurse is going to stand silently and pointlessly in the corner. It makes one feel more self-conscious and takes the weirdness level up to Defcon 5. I felt like it turned a routine physical into a silent Victorian melodrama."

  So do male physicians make women more comfortable with intimate examinations by involving a chaperone or not? My bet is that bringing an aide in helps more than it hurts. But we don't know; the study has never been done. And that itself is evidence of how much we've underestimated the importance and difficulty of human interactions in medicine. Everything from etiquette to economics, from anger to ethics can work its way into a seemingly routine office appointment. The relationships are deeply personal, involving promises and trust and hope, and this is what makes doing well as a clinician more than a matter of outcomes and statistics. One must also do right. How to do right by patients can be uncertain, sometimes overwhelmingly so. Do you bring in a chaperone or not? If, on your examination, you find a mole and think it is worrisome but a second opinion disagrees, do you reconsider your diagnosis or not? When you've tried several treatments and they fail, do you keep fighting or do you stop? Choices must be made. No choice will always be right. There are ways, however, to make our choices better.

  What Doctors Owe

  It was an ordinary Monday at the Middlesex County Superior Court in Cambridge, Massachusetts. Fifty-two criminal cases and a hundred and forty-seven civil cases were in session. In courtroom 6A, Daniel Kachoul was on trial on three counts of rape and three counts of assault. In courtroom 10B, David Santiago was on trial for cocaine trafficking and illegal possession of a deadly weapon. In courtroom 7B, a scheduling conference was being held for Minihan v. Wallinger, a civil claim of motor vehicle negligence. And next door, in courtroom 7A, Dr. Kenneth Reed faced charges of medical malpractice.

  Reed was a Harvard-trained dermatologist with twenty-one years of experience, and he had never been sued for malpractice before. That day, he was being questioned about two office visits and a phone call that had taken place almost a decade earlier. Barbara Stanley, a fifty-eight-year-old woman, had been referred to him by her internist in the summer of 1996 about a dark warty nodule a quarter-inch wide on her left thigh. In the office, under local anesthesia, Reed shaved off the top for a biopsy. The pathologist's report came back a few days later, with a near-certain diagnosis of skin cancer--a malignant melanoma. At a follow-up appointment, Reed told Stanley that the growth would have to be completely removed. This would require taking a two-centimeter margin--almost an inch--of healthy skin beyond the lesion. He was worried about metastasis, and recommended that the procedure be done immediately, but she balked. The excision that he outlined on her leg would have been three inches across, and she couldn't believe that a procedure so disfiguring was necessary. She said that she had a friend who had been given a diagnosis of cancer erroneously and undergone unnecessary surgery. Reed pressed, though, and by the end of their discussion she allowed him to remove the visible tumor that remained on her thigh, only a half-inch excision, for a second biopsy. He, in turn, agreed to have another pathologist look at all the tissue and provide a second opinion.

  To Reed's surprise, the new tissue specimen was found to contain no sign of cancer. And when the second pathologist, Dr. Wallace Clark, an eminent authority on melanoma, examined the first specimen he concluded that the initial cancer diagnosis was wrong. "I doubt if this is melanoma, but I cannot completely rule it out," his report said. Reed and Stanley spoke by phone in mid-September 1996 to go over the new findings.

  None of this was in dispute; what was in dispute was what happened during the phone call. According to Stanley, Reed told her that she did not have a melanoma after all--the second opinion on the original biopsy "was negative"--and that no further surgery was required. Reed recalled the conversation differently. "I indicated to Barbara Stanley that Dr. Wallace Clark felt that this was a benign lesion called a Spitz nevus and that he could not be a 100 percent sure it was not a melanoma," he testified. "I also explained to her that in Dr. Clark's opinion this lesion had been adequately treated, that follow-up would be necessary, and that Dr. Clark did not feel that further surgery was critical. I also explained to Barbara Stanley that this was in conflict with the previous pathology report and that the most cautious way to approach this would be to allow me to [remove additional skin] for a two-centimeter margin." She became furious at him for the seeming error in his initial diagnosis, though, and told him that she didn't want more surgery. "At that point, I reemphasized to Barbara Stanley that at least she should come in for regular follow-up." She didn't want to return to see him. Indeed, she wrote him an angry letter afterward accusing him of mistreatment and refusing to pay his bill.

  Two years later, the growth reappeared. Stanley went to another doctor, and this time the pathology report came back with a clear diagnosis: a deeply invasive malignant melanoma. A complete excision, she was told, should probably have been done the first time around. When she finally did undergo the more radical procedure, the cancer had spread to lymph nodes in her groin. She was started on a yearlong course of chemotherapy. Five months into it, she suffered a seizure. The cancer had spread to her brain and her left lung. She had a course of radiation. A few weeks after that, Barbara Stanley died.

  But not before she had called a lawyer from her hospital bed. She found a full-page ad in the Yellow Pages for an attorney named Barry Lang, a specialist in medical malpractice cases, and he visited her at her bedside that very day. She told him that she wanted to sue Kenneth Reed. Lang took the case. Six years later, on behalf of Barbara Stanley's children, he stood up in a Cambridge courtroom and called Reed as his first witness.

  MALPRACTICE SUITS ARE a feared, often infuriating, and common event in a doctor's life. (I have not faced a bona fide malpractice suit yet, but I know to expect one.) The average doctor in a high-risk practice like surgery or obstetrics is sued about once every six years. Seventy percent of the time, the suit is either dropped by the plaintiff or won by the doctor in court. But the cost of defense is high, and when doctors lose, the average jury verdict is half a million dollars. General surgeons pay anywhere from thirty thousand to three hundred thousand dollars a year in malpractice-insurance premiums, depending on the litigation climate of the state they work in; neurosurgeons and obstetricians pay upward of 50 percent more. This is a system that seems irrational to most physicians. Providing medical care is difficult. It involves the possibility of any of a thousand missteps, and no doctor will escape making some terrible ones. Lawsuits demanding six-figure sums for bad outcomes, therefore, seem mostly malicious to physicians--and even worse when no actual mistake is involved.

  Every doctor, it seems, has a crazy-lawsuit story. My mother, a pediatrician, was once sued after a healthy two-month-old she had seen for a routine checkup died of sudden infant death syndrome a week later. The lawsuit alleged that she should have prevented the death, even though a defining characteristic of SIDS is that it occurs without warning. One of my colleagues performed lifesaving surgery to remove a woman's pancreatic cancer only to be sued years later because the woman developed a chronic pain in her arm; the patient blamed it, implausibly, on potassium that she received by IV during recovery from the surgery. I have a crazy-lawsuit story of my own. In 1990, while I was in m
edical school, I was standing at a crowded Cambridge bus stop when an elderly woman tripped on my foot and broke her shoulder. I gave her my phone number, hoping that she would call me and let me know how she was doing. She gave the number to a lawyer, and when he found out that it was a medical school exchange he tried to sue me for malpractice, alleging that I had failed to diagnose the woman's broken shoulder when I was trying to help her. (A marshal served me with a subpoena in physiology class.) When it became apparent that I was just a first-week medical student and hadn't been treating the woman, the court disallowed the case. The lawyer then sued me for half a million dollars, alleging that I'd run his client over with a bike. I didn't have a bike, but it took a year and a half--and fifteen thousand dollars in legal fees--to prove it.

  My trial had taken place in the same courtroom as Reed's trial, and a shudder went through me when I recognized it. Not everyone, however, sees the system the way doctors do, and I had come in an attempt to understand that gap in perspectives. In the courtroom gallery, I took a seat next to Ernie Browe, the son of Barbara Stanley. He was weary, he told me, after six years of excruciating delays. He worked for a chemistry lab in Washington State and had to take vacation time and use money from his savings to pay for hotels and flights--including for two trial dates that were postponed as soon as he arrived. "I wouldn't be here unless my mother asked me to, and she did before she died," he said. "She was angry, angry to have lost all those years because of Reed." He was glad that Reed was being called to account.