Draping in Dermatology: A Physician’s Perspective

Abstract

Background

Patient dignity is a core component of medicine and health care, yet maintaining patient dignity can be challenging in clinical settings in dermatology, specifically during a total body skin examinations (TBSE) for appropriate assessment and diagnosis. A recent study evaluated patient perspectives in dermatology. The purpose of this study was to investigate current draping practices and perspectives from a physicians’ perspective.

Methods

A cross-sectional study was performed with the use of study-specific questionnaire distributed to staff dermatologists and dermatology residents across Canada.

Results

A total of 117 physicians were included (84 attending dermatologists and 33 dermatology residents). Nearly all staff and resident dermatologists (90.6%) indicated that draping was important. Specific practices differed between residents and staff (P = .03). Only 3.1% of residents indicated that they did not receive any form of teaching on draping during their training compared to 21.4% of attending physicians (P = .03).

Discussion

This study confirms that draping practices in dermatology are perceived as important by dermatologists, consistent with other reports emphasizing approaches to protect patient privacy and dignity. There is a shared value for draping and consistent integration of this within current practice of Canadian dermatologists. Formal and informal education incorporated in medical education and dermatology training is becoming more prominent. Major study limitations include sampling bias, convenience bias and nonresponse bias.

Conclusion

This is the first study to evaluate physician perspectives on draping in dermatology or other areas in medicine. Findings from this study support a focus on draping in medical education.

Introduction

The ability to maintain every patient’s dignity, which is characterized by respect, autonomy, empowerment, and communication, is of utmost importance in clinical settings. In medical and allied healthcare settings, this is often facilitated by covering undressed patients with drapes, or using physical barriers, during physical examination and procedures or interventions. While there is an abundance of literature that addresses the use of sterile drapes and patient positioning in the context of bedside procedures or operative fields, there are few studies that focus on the use of draping techniques and its role in addressing issues surround patient dignity from a physician’s perspective, and there are no studies evaluating the use of draping in dermatology settings.

The College of Physicians and Surgeons of Ontario published an article and video in an attempt to standardize draping of patients. ¹ This video highlights the importance of verbal communication, consent, privacy, limiting exposure times, and empowering patients to move the drape themselves, as well as to ‘only expose the area of the body being directly examined.’ ¹ The latter, however, is not realistic for dermatologists when performing a total body skin exam (TBSE) due to the need for a patient to remove all clothing during a physical examination for adequate assessment and diagnosis. The TBSE is generally employed to visualize large surface areas of the skin at once during a single examination and provide a complete perspective of the extent and distribution of skin disease, both keys to accurate diagnosis, as well as reduce the risk of missing individual lesions. ² A key measure to enhance patient dignity in dermatology settings is through appropriate draping prior to a TBSE, where the approach aims to increase a patient’s experience in terms of comfort, control and sense of value during a potentially sensitive examination such as the TBSE, yet not compromise a thorough medical examination. ³ Our group recently investigated the subjective patient experiences and knowledge surrounding draping practices during TBSEs in a dermatology setting which confirmed the positive role that draping holds in enhancing patient privacy and dignity for the patient experience. ⁴ These findings are similarly supported through studies performed in other clinical settings and allied health professions, such as physiotherapy and massage, in which draping practices are ubiquitous to the physical examination. ^5,6

Despite the central role of draping as a tool to maintain patient dignity in medicine, there is no standardized draping practice that exists for a general patient population. This means that both resident and attending physicians each have a unique way of draping their patients that is not standardized nor rigorous. Resident and attending physicians often develop competence in common bedside practices and etiquette that are not formally taught. The philosophy of “see one, do one, teach one”, a form of vertical transmission of potentially unreliable knowledge, continues to be deeply ingrained in medical training, which potentially contributes to gaps in knowledge and possible subjective discomfort when implementing bedside procedures, such as draping, in clinical practice. ⁷ This apprenticeship model of education that exists for various bedside procedures and measures that maintain patient dignity runs counter to the evidence-based model of training needed to prepare the next generation of physicians. ⁷ This therefore elicits an overarching research question in clinical practice and medical training to investigate whether standardized draping techniques and formal teaching are beneficial to dermatologists in their practice in order to maintain patient dignity without compromising patient care.

This is the first study to examine draping practices in a dermatology setting as experienced by staff dermatologists and residents in dermatology training. Adding to our earlier study examining the patient-perspective towards the use of draping in their experiences and care in a dermatology setting, ⁴ the primary aim of this study is to evaluate resident and attending physician education and experiences of draping practices during TBSEs in a dermatology setting. Secondary outcomes will aim to further elucidate resident and attending physician knowledge of draping practices, comfort with regards to skin examination and draping, as well as perceived importance of draping and potential barriers to draping. The ability to understand and maintain every patient’s dignity in clinical settings remains of utmost importance in this study.

Methods

Study Design

A cross-sectional study evaluating draping practices and comfort levels in dermatology clinical settings was performed with the use of an online questionnaire (Appendix 1) which was available online and distributed to attending dermatologists and dermatology residents across Canada.

Participants

A total of 117 participants across academic institutions in Canada completed the survey (84 attending dermatologists and 33 dermatology residents) between January 2021 to June 2021. All participants were approached by research investigators by email and were offered to participate in the study through the completion of the online questionnaire with the option to complete this in either English or French, based on their preference. An initial email which included a summarized description of the study protocol as well as the study survey link was disseminated through the Canadian Dermatology Association (CDA) membership email list, as well as distributed to each respective Division of Dermatology contact list of current residents and staff. Participants were also recruited through direct contact by study investigators.

All residents of any post-graduate training level as well as any dermatology staff was eligible to complete 1 survey. Participation in the study was voluntary and anonymous. There was no compensation nor follow-up for participants who completed the survey. Incomplete surveys were excluded from the study. Clinic staff at every institution were blinded to all aspects of the study to minimize any potential bias from the modifications of behaviors.

Surveys

A study-specific survey was developed by the researchers (included in supplementary material). The survey consisted of two major components: (1) baseline demographic characteristics including sex, age, province of practice, year of training and in practice, and (2) 8 self-reported questions regarding experiences of draping practices, education and perceived barriers as well as an opportunity to provide additional comments though open-ended answers.

Outcome Measures

Primary outcomes included dermatology staff and resident perceived importance of draping, physician draping practices including the frequency and type of drape used, and their comfort level with draping. Additionally, the extent of teaching on draping during residency training, knowledge about draping and the biggest barriers to draping including time restraints, lack of education/knowledge and lack of supplies/materials were also assessed.

Ethics Approval

Ethics approval was obtained through the Research Ethics Board at The Ottawa Hospital for physician administered surveys. All surveys and administration were conducted according to the World Medical Association Declaration of Helsinki.

Statistical Analysis

Data collected from the surveys was compiled into a centralized database designed specifically for the study using Microsoft Excel. The data were summarized in a table format using descriptive statistics (means, ranges). Qualitative data from open-ended answers was collected and summarized by theme, as depicted in Supplemental Figure 1.

Results

A total of 117 attending dermatologists (n = 84) and dermatology residents (n = 33) across Canada responded to the survey and were included in the study and demographic information summarized in Supplemental Table 1. Both resident and attending physician respondents were of varied years of training or years of practice. There was varied representation of respondents from provinces across Canada; however, there were no respondents in training or in practice in Saskatchewan. Self-reported attitudes surrounding providing a drape in a clinical setting, draping practices, and factors potentially affecting draping practices are summarized in Supplemental Table 2.

Self-Reported Attitudes and Experiences Surrounding the Use of a Drape in a Clinical Setting

The importance of draping in a clinical setting was identified as either very important or fairly important in 90.6% of all respondents, and 67.5% of all respondents indicated that they always offer a drape during TBSE. Nearly all resident and attending physicians indicated that draping is very important (63.6% of residents, 61.9% of attending physicians) or fairly important (30.3% of residents, 26.2% of attending physicians) which was a similar response for both groups (P = .99). The primary type of drape provided was a gown in both attending physician (57.1%) and resident (45.5%) respondents, however a larger proportion of resident respondents reported offering both a gown and sheet for draping instead of gown or sheet only (39.4%, compared with 14.3% of attending physicians, P = .03). The same proportion of resident and attending physician respondents also reported that they “always” think about draping and the patient’s privacy/dignity during a TBSE; 69% and 63.6% of respondents respectively (P = .89).

Comfort Level and Knowledge Surrounding Draping Practices

A total of 107 out of 117 respondents, or 91.45%, reported feeling either very comfortable or fairly comfortable with draping, however reporting on the extent of comfort level was different between attending physicians and residents, where 58% of attending physicians were very comfortable with draping, compared to only 33.3% of residents asked the same question (P = .068). Only 3.1% of residents indicated that they did not receive any form of teaching on draping during their training compared to 21.4% of attending physicians (P = .03). Self-reported knowledge about draping was higher in attending physicians, with 20.2% and 42.9% reporting either “excellent” or “good” knowledge about draping, respectively, whereas only 12.1% and 33% of residents reported similar feelings regarding their knowledge, though this difference did not reach significance (P = .14). Formal teaching was reported in 0.9% of all survey respondents.

Perceived Barriers to Effective Draping in a Clinical Setting

“Time restraints” was identified as the most important barrier to draping effectively in 51 of 117, or 43.6% of all respondents, which was the highest among other potential barriers. This trend was also seen within individual groups, such that 39.3% of attending physicians and 51.5% residents found this to be the most important barrier. This was followed by a lack of supplies/materials being a primary barrier (17.9% of attending physicians and 21.2% of residents). Notably, 9.4% of respondents including 15.2% of residents versus 7.1% of attending physicians admitted to lack of education/knowledge as the most important barrier to draping effectively. A larger proportion of attending physicians noted other barriers to effective draping in their practice (P = .04), with qualitative data from open-ended answers from survey participants, as described in Supplemental Figure 1.

Discussion

The primary aim of this study was to gain insight into dermatologists’ attitudes and knowledge towards the use of draping in their clinical practice, notably during the TBSE. Our findings confirm that the need to respect patient dignity is front-of-mind in dermatology based on perceived level of importance and frequency of offering a drape shared by resident and staff dermatologists. Both staff and resident dermatologists endorse frequently thinking about using a drape specifically in relation to their patient’s privacy and protection of patient dignity, thus suggesting that draping practices in dermatology are motivated at least in part by a conscious approach and sensitivity towards patients. When compared with a recent publication from our group, ⁴  physician versus patient views toward draping and its impact on dignity reveal an interesting contrast. While this study clearly demonstrates the shared value regarding the importance of draping amongst all staff and resident dermatologists without any significant difference between groups based on age or gender, patients’ attitudes towards draping were instead dependent on specific patient demographics and we found that younger female patients were significantly more affected by the use of draping practices in our sister study examining patient perspectives toward draping. ⁴ Findings from our patient survey convey a relative tolerance towards the TBSE and suggests that patients may appreciate the limitations of draping during TBSE in dermatology against the value of a complete and adequate physical examination. ⁴ At the same time, the physician-perspectives toward draping elicited in this study suggest that current Canadian staff and resident dermatologists are sensitive to the importance of draping for patient dignity. However, whether draping techniques are modified or adjusted based on anticipated comfort-levels of specific patient demographics was not evaluated in this study. Thus, despite this discrepancy between patient and physician perspectives on draping practices, dermatologists should continue to be mindful about the use of draping as a means to protect patient dignity during sensitive exams.

While both resident and staff dermatologists will almost always offer a drape during a TBSE in the form of a gown or sheet, there is some variation based on level of training such that residents more frequently provide both a gown and sheet, whereas attending physicians indicate use of a gown alone (P = .03). Residents in our study were younger (mean age = 30 years old) in comparison to the attending physician groups (mean age = 50 years old). It is possible that the younger age group of residents and inclination to provide extra forms of drape to patients is influenced by perceptions of body image, as suggested in McCabe and Ricciardelli’s review of the evolution of body image during different stages. ⁸ Another explanation could be that residents work in academic teaching centers where resources such as gowns and sheets are more plentiful rather than in the community practice settings where most Canadian staff dermatologists practice. Despite some differences in attitudes towards the role of draping in their practice, our findings suggest that both staff and resident dermatologist consistently integrate draping in their clinical practice, and moreover appear to approach draping with a degree of conscientiousness towards optimizing their patients’ comfort and overall experience of the TBSE.

Another major area of interest in the present study was knowledge and education underlying draping practices. This study strongly indicates that formal and informal education incorporated in medical education is becoming more prominent. Nearly all dermatology residents in this study received some level of informal and/or formal teaching on draping during their training, whereas this type of education has been absent for approximately 1 out of 5 staff dermatologists reaching statistical significance in this study (P = .03). For both groups, nearly all teaching on draping is provided through an informal approach compared to less than 10% of education on draping delivered through a mixed formal and informal curriculum. Importantly, education surrounding draping was also found to be a possible barrier to effective draping, which is supported further in the qualitative responses offered by residents and attendings (Supplemental Figure 1). Thus, while there appears to be an overall shift towards increasing efforts towards teaching draping practices during training, our findings suggest that the pedagogy is unchanged. This highlights a potential gap in current medical education and possible role for a formal curriculum item dedicated to draping practices during formative years in medical education or introduced to dermatology trainees during their residency program, and an opportunity for continuing medical education for practicing dermatologists. Emphasis on formal education on draping may help to support current practices of dermatologists in an evidence-based manner, as well as increase knowledge and comfort levels around draping and confidence with respect to protecting patient dignity during clinical assessments at earlier stages in training and their career. Of note, the majority of both staff dermatologists and residents identified time restraints as the most important barrier to effective draping in their clinical practice, which could also be addressed through a curriculum which emphasizes effective yet efficient draping practices. A larger proportion of attending physicians noted other barriers to effective draping in their practice which includes some notes on different approaches based on patient-specific factors or need for efficiency (complete qualitative responses described in Supplemental Figure 1).

While this study did sample current dermatologists at different stages of their career across Canada, a key limitation of this study is that the cohort was relatively small. In addition, a major limitation is that the total response rate for the results is unknown. This is due to the nature of survey dissemination through diverse outlets where the total number of contacts was not available, specifically with regards to indirect and third-party recruitment of participants through the CDA platform. Therefore, the ability to interpret the study findings within a broader scope of dermatologists in Canada is significantly jeopardized. The study findings are similarly limited by convenience sampling using program administrators of dermatology programs across Canadian academic institutions to share the survey through their respective email lists, as well as direct recruitment of prospective participants known to study investigators which compromises a statistically balanced population for analysis. A number of other important biases inherent to the study design and selection of study participants are also acknowledged, notably sampling bias, convenience bias, as well as nonresponse bias. This limits the validity and overall generalizability of the study findings and therefore definitive conclusions should be scrutinized. Finally, analysis of these findings and descriptive statistics did not reach statistical significance therefore definitive conclusions cannot be drawn. Larger-scale prospective studies could provide additional support for the findings elicited from this work and investigate which methods of draping are the most effective for patient comfort while also allowing for a competent TBSE to be performed. This would help shorten the time required to offer draping, and time restraints were perceived by both residents and attending physicians alike as the biggest barrier to draping. Future efforts should also be directed towards pedagogical approaches to teaching draping in medical education.

Conclusion

This is the first study to focus on the perspectives of resident and attending dermatologists towards draping in a clinical setting. Currently dermatologists and dermatology residents appear to value the role of adequate draping and have a conscientious approach when implementing draping as a means to maintain patient dignity in a dermatology setting. There is an indication that medical education focussing on draping is becoming more prominent in training, however there is opportunity for enhancing and formalizing this education.

Supplemental Material

Table S1 - Supplemental material for Draping in Dermatology: A Physician’s Perspective

Supplemental material, Table S1, for Draping in Dermatology: A Physician’s Perspective by Louise Gresham, Justina Melkis, Bohmyi Choi, Janelle Cyr, Christina M. Huang and Jennifer Beecker in Journal of Cutaneous Medicine and Surgery

Supplemental Material

Table S2 - Supplemental material for Draping in Dermatology: A Physician’s Perspective

Supplemental material, Table S2, for Draping in Dermatology: A Physician’s Perspective by Louise Gresham, Justina Melkis, Bohmyi Choi, Janelle Cyr, Christina M. Huang and Jennifer Beecker in Journal of Cutaneous Medicine and Surgery

Supplemental Material

Figure S1 - Supplemental material for Draping in Dermatology: A Physician’s Perspective

Supplemental material, Figure S1, for Draping in Dermatology: A Physician’s Perspective by Louise Gresham, Justina Melkis, Bohmyi Choi, Janelle Cyr, Christina M. Huang and Jennifer Beecker in Journal of Cutaneous Medicine and Surgery