Chaperones for intimate examinations

Physical examinations are difficult—and not just for medical students. At a time when patients feel vulnerable, isolated, and fearful doctors may blithely ask them to strip from “nipples to knees.” Appropriate exposure, necessary clinically, may conflict with the patients’ own expectations of what’s required and appropriate. This conflict sometimes ends up being played out in law courts and litigation claims.

Increasingly, doctors are being asked to seek chaperones for “intimate” physical examinations. And some recent rulings against individual doctors have stipulated that they may only continue to practise with chaperones present during clinical examinations.

In February this year, for example, the General Medical Council ruled that a doctor from Devon, charged with viewing child pornography, could continue to practise only with chaperones present during consultations. In Australia a doctor has been ordered to have chaperones present during examinations, at least until he is cleared of ongoing criminal charges about the indecent assault of a female patient.

The Department of Health and the GMC have both recently published guidelines on using chaperones. And for medical students, meanwhile, the phrase “before proceeding, I’d like to request a chaperone,” is now as much a part of the well rehearsed preamble to objective structured clinical exams as the theatrical washing of hands.

In a London hospital

But introducing chaperones into consultations causes its own problems, and current clinical practice varies greatly. Steve Estreich, a consultant in genitourinary medicine at St Helier Hospital in London, says that the new emphasis on chaperones creates pressure on already hard pressed resources.

“Clearly people aren’t employed as professional chaperones, people are employed to do other things,” he explains. “So when you ask someone to come into the room as a chaperone you drag them away from what they’re doing.”

The guidelines used at Dr Estreich’s clinics state that “all patients in genitourinary medicine should be offered a chaperone when an intimate procedure is to be undertaken.” Dr Estreich, however, says that it’s “very unusual” for men to take up the offer of having a chaperone. “And if they did, it’s unclear how we’d resource it.”

Recent studies back up Dr Estreich’s anecdotal experience of sex difference in the demand for chaperones. A study at Charing Cross Hospital, for example, found that more than half of women accepted the offer of chaperone, compared with just 5% of men (Sexually Transmitted Infections 2004;80:250).

The St Helier guidance goes one step further than simply accommodating requests for chaperones—it insists they be present when male doctors examine women. If a patient refuses this, the examination must be deferred until a female practitioner can perform it.

Protecting doctors

This brings into focus one of the primary rationales for the introduction of chaperones: the protection of the doctor from either misunderstandings or malicious allegations. It’s a point that the US surgeon Atul Gawande makes in his 2007 book, Better: “One of every two hundred [US] physicians is disciplined for sexual misconduct with patients sometime during his or her career . . . the vast majority of cases involved male physicians and female patients, and virtually all occurred without a chaperone present.”

And it’s not just court cases that may confront un-chaperoned medics: “A 1994 study found that 72% of female medical students and 29% of male students experienced at least one instance of patient initiated sexual behaviour,” he notes.

GMC figures show that since April 2006 there have been 77 cases that have contained allegations of improper relationships with patients, attempted rape, or rape. Of these, 12 have been referred to a hearing, of which eight remain unheard. The remaining four resulted in erasure from the register for three of the doctors with one receiving a warning.

Sally Old from the UK Medical Defence Union emphasised that the nebulous notion of “intimacy” ought to be defined by the patient rather than the doctor: “During a fundoscopy examination, for example, the lights are down and we get extremely close to the patient. Doctors may not consider that intimate, but patients might, and misunderstandings could result. So it’s important to explain procedures carefully,” says Dr Old, “even for exams that medics might consider standard.”

Who can be a chaperone?

Offering a chaperone is one thing, settling on a suitable candidate is another. “If you choose a member of the practice staff, that may not seem ‘neutral’ to the patient,” says Dr Estreich. “But on the other hand a member of the patient’s family might not be suitable from the doctor’s point of view, either.”

The GMC says blandly that the chaperone should be familiar with the examination being performed and should be able to comfort the patient, respect their dignity, and preserve confidentiality. It does say that in “some circumstances a relative or friend of the patient may be an acceptable chaperone.”

Chaperones may prevent some unwarranted allegations, but there are no guarantees. The Medical Defence Union have dealt with cases in which allegations were made despite a chaperone being present. In one such case reported in GP Magazine a doctor was accused of indecency during a smear test (www.healthcarerepublic.com, 1 Feb, “The function of a chaperone”). It was eventually dismissed by the GMC, but not before the doctor had endured a painful public hearing.

Some people may consider chaperones to be an example of “defensive medicine”—practice based on avoiding litigation rather than pursuing the patients’ interests. Clearly, there are some patients who would rather not be exposed to a third pair of eyes during intimate examinations. Equally there are some doctors who worry about the sanctity and confidentiality of the doctor-patient consultation being infringed.

But given that the boundaries between doctors and patients may be less obviously maintained than previously—for example, terms of address are familiar and uniforms more relaxed—and that the prospect of litigation is real and relevant, it seems sensible to take steps such as chaperoning to avoid misunderstandings.

Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

The GMC guidance, Maintaining Boundaries, is at www.gmc-uk.org/guidance/current/library/maintaining_boundaries.asp.

      

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