Why it is important to use a chaperone
Kirsty Sharp outlines the importance of using chaperones during intimate examinations and other examinations where there could be potential for misunderstanding
Read this article to:
Understand the importance of a chaperone during intimate examinations and other examinations where there could be potential for misunderstanding, such as during chest auscultatory examinations
Learn from a case study to see how the presence of a chaperone protected the doctor from further action
Understand the guidance given to you by the medical council
Many patients will find being examined by a doctor embarrassing; however, a physical examination is an important part of an assessment of a patient.
Conducting physical examinations present certain risks to doctors, who sometimes may not always be alive to the dangers of some examinations. For example, an accidental brush of the chest can get doctors into difficulty. Occasionally, even an inappropriate remark can also tip the patient into an uncomfortable state of mind which can lead to the doctor's actions being misconstrued.
Medical Protection has recently seen an increase in the number of cases where members have been accused of inappropriate touching or conduct during a chest examination for respiratory or cardiac assessment. Assessments such as these have the potential for misunderstanding – doctors should apply the same precautions to these types of assessments as they do when conducting intimate examinations.
Obvious examples of intimate examinations include those of the breasts, genitalia and rectum, but it can also extend to any examination where it is necessary to touch or be close to the patient; for example, conducting eye examinations in dimmed lighting and palpating the apex beat.
In these situations where misunderstanding can occur, you should let the patient know that they may have a chaperone present if they wish. The offer of a chaperone is for the protection of both the patient and the doctor.
How to use a chaperone
Offer a chaperone to all patients for intimate examinations and examinations that may be construed as such.
Establish that there is a need for an intimate examination and discuss this with the patient.
Explain why an examination is necessary and give the opportunity to ask questions; obtain and record the patient's consent.
If the patient does not want a chaperone, record this in the notes.
If the patient declines a chaperone and as a doctor you would prefer to have one, explain to the patient that you would prefer to have a chaperone present and, if they decline, you can decline to treat them.
Explain what you are doing at each stage of the examination, the outcome when it is complete and what you propose to do next. Keep the discussion relevant and avoid personal comments.
Record the identity of the chaperone in the patient's notes.
Record any other relevant issues or concerns immediately after the consultation.
In addition, keep the presence of the chaperone to the minimum necessary period. There is no need for them to be present for any subsequent discussion of the patient's condition or treatment.
We have a useful flowchart that provides a step-by-step guide for doctors in the use of chaperones. The flowchart is available to read and download on page 8 of this PDF.
A 33-year-old female patient, Mrs B, consulted Dr W for vomiting and a migraine.
Mrs B complained to the medical council that Dr W did a few things which made her feel uncomfortable. The allegations of unprofessional conduct included:
Dr W touched her right breast when taking her blood pressure.
During auscultation Dr W put the stethoscope inside her t-shirt without warning.
Dr W could not remember any issues with that patient on that day.
He recalled:
"I may have accidentally brushed her chest during the procedure. However, a proper chest examination requires placing the stethoscope directly on the skin to avoid acoustic artefacts from the clothing."
"It is my standard practice to have a chaperone when I examine female patients. She may not have noticed that my assistant was standing behind her after she sat down during the consultation."
Medical Protection assisted Dr W to respond to the PIC investigation.
Medical Protection conducted an audit of Dr W's previous consultations, and was able to prove that it was his consistent practice to have a chaperone and document it when examining female patients – this helped his defence.
An important point to make is that Mrs B's consultation was not an intimate examination – it was a chest examination – but Dr W ensured he had a chaperone in the room.
In this situation the importance of a chaperone was paramount. It should be remembered that a chaperone also protects the doctor from unfounded allegations, as demonstrated in this case.
Although Dr W correctly ensured a chaperone was present during the examination, he failed to check the patient was aware of the chaperone in the room and ensure that the patient had agreed to having a chaperone present. (agreement to having a chaperone is not "an informed consent" issue)
It is important that chaperones should have appropriate training and they should usually be a health professional.
It is important that the offer, presence or declining of a chaperone is documented in the patient's notes, along with any rationale for continuing without a chaperone when the doctor would have preferred one was present.
Official guidance
Medical councils are clear in their guidance that in intimate examinations chaperones should be considered. The Medical Council of Hong Kong, in its Code of Professional Conduct (2016), states that: "It is advised that an intimate examination of a patient is conducted in the presence of a chaperone which the patient has agreed to. If the patient requests to be examined without a chaperone, it is important to respect the patient's preference but the doctor should then consider carefully why that is and whether it is safe or essential to continue with the examination without a chaperone. It is also recommended to record the patient's unusual request in the medical records."
The Malaysian Medical Council, in Good Medical Practice (2001), states that: "A doctor must always examine a patient, whether female or male, or a child, with a chaperone being physically present in the consultation room, with visual and aural contact throughout the proceedings.
"A relative or friend of the patient is not a reliable chaperone as he or she may not fully appreciate the nature of the physical examination performed by the doctor and may even testify against the doctor in the event of allegations of misconduct or physical abuse. More importantly the patient may have a need for confidentiality or could well be embarrassed by having a close family or friend witness an intimate examination. Similarly, a relative of the doctor (wife, daughter, etc), who is not an impartial observer, could be prejudicial as a chaperone."
In the Singapore Medical Council guidelines, Ethical Code and Ethical Guidelines (2016), it states that: "When you need to ask intimate questions or examine intimate parts of the body, you must explain the need to do so and be sensitive to any discomfort or hesitancy on patients' part and reconsider your approach if they express discomfort.
"You must ensure that during clinical examination, your approach would leave reasonable patients feeling safe, secure and comfortable in your presence, without any misconception or fear that their modesty is being compromised or that you are taking advantage of them for your own gratification.
"If your patients indicate that they would be more comfortable having a chaperone for clinical examination, or you assess them to be so, you must have a chaperone present. If in your judgment of the situation you are better protected if there is a chaperone, you may insist on having one present. If despite your explanations and reassurances patients object, you may decline to examine them until a mutually acceptable chaperone is available."
While utilising a chaperone effectively isn't an omnipotent safeguard from complaints and claims, it can provide significant protection and assistance in some sensitive situations. More importantly it signifies awareness and respect of your patient's needs, which is an important building block in a trusting doctor–patient relationship.
The Medical Council of Hong Kong – Code of Professional Conduct (2016)
The Malaysian Medical Council – Good Medical Practice (2001)
Singapore Medical Council guidelines, Ethical Code and Ethical Guidelines (2016)
More support from Medical Protection
For medicolegal advice contact:
Hong Kong: 800 908 433 or querydoc@medicalprotection.org
Malaysia: 1 800 81 5837 or querydoc@medicalprotection.org
Singapore: 800 616 7055 or querydoc@medicalprotection.org
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