Ms Suzanne Creed, Clinical Risk Advisor at Medisec, provides advice concerning the use of chaperones for intimate medical examinations
A chaperone is an impartial observer, present during an intimate examination with a patient. They provide protection for both the patient and the clinician. This can prove important should a clinician face allegations of impropriety. In 2019, almost five per cent of all complaints made to the Medical Council included allegations about physical and intimate examinations. For any doctor an accusation of inappropriate behaviour towards a patient is devastating and the consequences can be far-reaching. Cases can take many months, and often years, to resolve, by which time the doctor concerned may have been through criminal, civil, and Irish Medical Council proceedings, as well as facing adverse publicity in the media. It is therefore important that clinicians are fully aware of their ethical responsibilities and protect themselves by complying with chaperone guidance.
The Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners provides clear guidance concerning the use of chaperones for intimate examinations. Paragraph 35 states:
35.1 Clinical assessments of patients often involve a physical examination as well as relevant history-taking. Before undertaking any physical examination, including an intimate examination, you should explain to patients why it is needed and what will be involved and get their consent.
35.2 You should respect patients’ dignity by giving them privacy to undress and
dress and keeping them covered as much as possible. You should not help the patient to remove clothing unless they have asked you to do so, or you have checked with them that they want your help.
35.3 Where an intimate examination is necessary, you must explain to the patient why it is needed and what it will entail. You must ask the patient if they would like a chaperone to be present – for example, a nurse or family member – and note in the patient’s record that a chaperone was offered. You should also record if a chaperone was present, had been refused, or was not available, but the patient was happy to proceed.
35.4 You must not carry out intimate examinations on anaesthetised patients unless the patient has given written consent to this in advance.
The use of a chaperone for intimate examinations is also endorsed by the HSE.
What is an intimate examination?
Examination of the breast, genitalia, and rectum are commonly recognised as intimate examinations. However, some patients may consider any examination in which the doctor needs to touch or be very close to them as intimate, for example, ophthalmic examination in a darkened room where physical proximity is necessary. Similarly, if a patient is vulnerable in any way, where prior misunderstandings exist or for cultural or religious reasons it may be appropriate for the doctor to offer a chaperone. It is therefore important that doctors use their clinical judgement to determine if an examination is intimate depending on the individual circumstances
and irrespective of the gender of the patient or clinician.
Selecting a chaperone
The role of the chaperone is to act as an impartial observer, providing reassurance to the patient and to raise any concerns about a doctor’s behaviour or actions. Ideally, the chaperone should be a trained health professional familiar with the examination being undertaken so that, if necessary, they can confirm the examination was appropriately conducted.
A trained chaperone may also feel more comfortable raising questions or concerns about how the examination is conducted. If non-medical staff members, eg, secretary/administrator, are to undertake the chaperone role, you should ensure that they are fully trained, which includes training in maintaining patient confidentiality, familiarity with the procedure, where to position themselves during the examination, and how to raise concerns about a healthcare professional if misconduct occurs.
What to do if a chaperone is unavailable
There may be occasions when a chaperone may not be available, such as on home visits or in an out-of-hours setting. In these circumstances, you should consider whether the examination is urgent and necessary. If it is not urgent and the patient requests a chaperone, you could reschedule the appointment for a time when a chaperone is available.
If a patient declines a chaperone
The presence of a chaperone protects both the doctor and the patient. Even if a patient declines a chaperone, the doctor may feel it would be more prudent to have one for their own protection and/ or comfort. In such circumstances, the doctor should explain their position to the patient. If the patient still declines the offer of a chaperone, the doctor will need to determine whether they are happy to proceed with the examination or not. This is a personal decision that the
doctor will need to make, exercising their own clinical skills and judgement. If the doctor does proceed in the absence of a chaperone, they should carefully document that a chaperone was offered and declined. It is advisable that the doctor also makes a note detailing their rationale for undertaking the examination in the absence of a chaperone.
In all instances where a chaperone has been offered, it should be recorded in the patient’s clinical file whether it has been accepted or declined. Where a chaperone has been used, their identity, including name and job title, should also be recorded. If you use electronic records, you may find it useful to use a chaperone template to record the patient’s relevant decision.
Some clinicians may try to alleviate patients’ anxiety during sensitive examinations by using humour, making lighthearted comments, sharing personal stories, or minimisng the significance of the examination. While it’s natural to try to put patients at ease, the prevailing wisdom is that these types of comments can be misinterpreted by the patient and are best to be avoided.
In Medisec’s experience, the best way to minimise patient discomfort in these situations is to communicate clearly with the patient, be personable and compassionate and ensure that your personal behaviour remains professional throughout, so as to be beyond reproach.
A key focus in all clinical encounters should be an evaluation of whether to use a chaperone for some or all physical examinations. This should be done regardless of the gender of the patient or the clinician and irrespective of the long-term nature of the doctor-patient relationship. Chaperones can offer protection and comfort for doctors and patients, particularly during intimate examinations.
References on request
1. Develop a chaperone policy for your practice/organisation. Consider displaying your policy on your website and/or in your waiting room via a poster.
2. If an intimate examination is required, you should explain the nature of the procedure/examination and obtain the patient’s consent to proceed. If you need to modify the examination while it is underway, inform the patient and reconfirm consent.
3. Allow the patient time to ask any questions about the procedure. Be aware of, and respect, any cultural or religious issues.
4. Offer a chaperone to all patients for intimate examinations (or examinations which could be construed as such) – irrespective of the gender of the patient and the clinician.
5. Always respect patient privacy by providing an appropriate space to undress/re-dress. This applies to the clinician, your staff, and the chaperone.
6. Keep all conversations professional and avoid any personal or inappropriate comments.
7. The chaperone should stand in a position where they can see the patient and the process of the examination.
8. The chaperone should leave the room following the examination. They do not need to be present for any subsequent discussion of the patient’s condition or treatment.
9. Immediately after the consultation record the identity and job title of the chaperone, as well as any other relevant issues or concerns.
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