Provide comfort and support for the patient and protection for the Doctor

Never, sometimes, or always characterise the wide variation in individual doctors' practice of using chaperones during genital and rectal examination. This variation is not confined to general practice.¹ In this month's issue Torrance et al have reported a survey of chaperone policy in genitourinary medicine clinics.² Some clinics would appear to allow male doctors to examine female patients without the presence or offer of a chaperone. Such practice is surely beyond justification.

Some may argue that the use of chaperones is an area where physician discretion is more relevant than policy. Certainly not all patients choose to have a chaperone present during intimate examinations, and it may be difficult to provide chaperones in some settings. However, in this area of quality and clinical risk guidelines rather than discretion need to dictate practice.

What considerations should direct the use of chaperones? Several studies have sought patient preferences in primary and secondary healthcare settings,^{3 7} although not in genitourinary medicine. The findings show remarkable consistency. Male and female patients differ markedly in their desire for a chaperone. Most women want the offer of a chaperone and feel uncomfortable asking for one if it is not offered. Most teenagers want a chaperone during intimate examinations, and a family member may be the preferred choice. Many women prefer having a third party present when the examining doctor is male, fewer if the examining doctor is female. For women a female nurse is generally the preferred choice as chaperone, would be accepted as a routine part of the clinical examination, and is generally viewed as having a positive supporting role during the examination. Men, however, particularly teenagers, find the presence of a female nurse as observer during genital examination unwelcome. Interestingly, a substantial proportion of patients in primary care didn't mind if a chaperone was present or not,⁷ although this finding may reflect an older patient sample and familiar doctors.

These findings suggest some strong imperatives. Every woman having a genital or rectal examination should be offered a chaperone. Failure to offer one deprives patients of support they may want, and non-availability is an unacceptable excuse. It is unacceptable for a teenage woman to be alone with an unfamiliar male physician for genital examination. Moreover, it shouldn't be assumed that a female nurse will be an acceptable chaperone for a man.

Genital examination is one area of medical practice where the sex of the patient and sex of the doctor have a significant influence on patient preferences. Clear differences exist in the preferences of male and female patients, and these can and should be accommodated. In genitourinary medicine it is difficult to argue against a female nurse routinely being present during the examination of women to support the patient and provide assistance to the examining doctor, regardless of the sex of the doctor. Assistance is rarely required in examination of male patients, who generally do not express a need for the support of a chaperone and are likely to feel embarrassed if one is present. Teenagers, however, are probably more apprehensive about genital examination than older patients. They are a major patient group in genitourinary medicine clinics, and their concerns need to be handled sensitively.

What other factors bear on chaperone use? Doctors have been accused of unprofessional conduct and sexual assault after unchaperoned examinations. Eight per cent of the women sampled by Webb and Opdahl reported experiences where doctors had conducted a gynaecological examination in a "less than professional manner."⁴ Unprofessional behaviour involved overexposure of the woman's body; inappropriate comments, gestures, or facial expressions; and being examined in an unusual position. Eight per cent of the lead physicians in genitourinary medicine clinics surveyed by Torrance et al were aware of allegations of unprofessional behaviour in their departments in the preceding five years.² For medicolegal protection therefore a third party should always be present during genital examination. It is, however, difficult not to proceed with a clinically indicated examination if the patient declines a chaperone, providing the physician feels comfortable in this situation. It would be prudent to document the patient's decision for an unchaperoned examination. It should also be recognised that in a few consultations - for example, the assessment of sexual dysfunction - the introduction of a third party for the examination might negatively affect the doctor-patient relationship.

Variations and inconsistencies in doctors' attitudes and practice in the use of chaperones have again been demonstrated. Examinations need to be conducted in an atmosphere characterised by sensitivity to patients' feelings, care, support, and respect for privacy, dignity, and patient choice. Such qualities are not discretionary. Most female patients in genitourinary medicine expect, welcome, and receive support from the presence of a female nurse. Policy should acknowledge this as best practice. Whether chaperoning should be more frequent during male genital examination is less clear and needs further study. Action is needed where practice is suboptimal and clear policies need to be formulated. Patient preference, the need for assistance, and medico legal considerations would seem to be the major determining factors.

A lesson learnt

A view from the other side

I was 18 and had just entered medical school when I visited my aunt and uncle who lived in the same city. After an evening's shopping we returned home, and just as my uncle was getting out of the car, he broke out in sweat and went very pale. He then became so short of breath that he was unable to walk from the car to the house. Realising that he was very ill, my aunt and I quickly rushed him to his local doctor in the next street. He gave him a couple of intravenous injections, whispered something to my aunt, and minutes later we were speeding along to the casualty department at my medical school.

By the time we arrived his breathing had become still more laboured and he was looking very grey. My aunt and I were then interrogated by a tired and irritable medical officer. "Has he had a heart attack before?" "Does he have any other diseases?" "What are his regular medications?" The questions were coming thick and fast. My aunt was too shocked and distressed to give any coherent reply. I suddenly remembered that my uncle had diabetes and I passed this information on and in response I was battered by another series of questions. "Is he on insulin?" "When did he have his last dose?" "Does he have any diabetic complications?" I had no answers. My apparent stupidity irritated the medical officer and he went away muttering about "useless relatives who are unable to provide any information."

In the meantime an electrocardiogram had been performed and within seconds we were hurrying down a long corridor and then up in a lift to the coronary care unit. Within minutes of his being transferred on to a bed there, his breathing seemed to become quieter. No one had given me the faintest idea of what, or indeed how serious, the problem was, and so when I saw him take a deep sigh and flop his head to one side, in my innocence I thought, "The injections are working and he has dozed off." The nurse attending to him obviously thought differently for she went into a panic, and suddenly a couple of doctors in white coats appeared out of nowhere and my aunt and I were bundled out of the unit. Just before the screens went round the bed I caught a glimpse of one of the doctors pounding my uncle's chest. My aunt was in tears, and I tried in vain to console her. After what seemed like an eternity, one of the doctors came to us. "There was nothing more that we could do," he said in an undertone. I just could not believe it. No one had prepared me for this terrible shock. Now 18 years later I am a seasoned hospital doctor, but that experience has taught me a lot about "the view from the other side." I had learnt that not everybody coming into hospital necessarily plans the visit and comes prepared for a detailed and satisfying interview with the doctor, although this is a fact that is all too easy to overlook as a harassed medical officer dealing with several medical emergencies in a busy casualty unit for long hours at a stretch. It has also taught me that when involved in the stressful situation of coping with an acute medical emergency you must not lose sight of the patient\'s relatives, as the doctor and the patient are not the only ones who are stressed.

Harish Kumar clinical research fellow, Birmingham