Consultation that calls for a chaperone
The distress and disruption caused by any allegation of inappropriate behaviour are to be avoided at all costs, says Dr Stefan Cembrowicz
Coming from a hard-pressed NHS hospital post you may be used to situations where, if you do examine patients unaccompanied, you are only nominally secluded by curtains or screens from a busy ward or A&E department, where other staff and patients are close by. During my own house jobs pressure of work meant that many examinations were simply carried out without chaperones as a matter of course.
When examining patients in your GP surgery or home surroundings the setting is quite different and doctor and patient may not be protected from misunderstandings – or worse – by the proximity of others.
Who should be offered a chaperone? A survey of 800 patients in the British Journal of General Practice1 showed most women (90 per cent) and men (78 per cent) would like to be offered a chaperone for an intimate examination and saw the offer as a sign of respect by the doctor.
Once given the choice, the survey found there are as many patients who resent the prescence of a chaperone as those who would always want one present. The findings highlighted the obvious point that people like to be offered choice in their management.
It is considered respectful and conventional good practice to offer everyone a chaperone, during any male-to-female intimate examination. ('Would you like the nurse to be with us while we do this examination?') Few patients will be offended by this offer; some who have known me for years dismiss it mirthfully ('What nonsense!').
Same-sex examinations Although I have never routinely offered a chaperone to my male patients (unless they fall into the categories below) I was a little surprised to see GMC advice on chaperones2 does not specify the sex of doctor or patient, that is the offer of a chaperone should apply to all intimate examinations. But at present many doctors do not routinely offer a chaperone to same-sex patients or during female-to-male/female-to-female examinations. There is no obvious choice of male chaperone, and men when surveyed expressed similar preferences to women.
Although most patients would feel uncomfortable with an unrequested chaperone, there are circumstances where it is sensible not to examine someone alone. When examining a minor, someone in a confused or misinterpretative state, in any situation where there is the slightest doubt about the patient's competence for consent, someone who may be under the influence of alcohol or medication (prescribed or otherwise), someone who has been sexually assaulted or where an intimate examination could be particularly distressing, such as a victim of childhood sexual abuse, it is wisest for your own peace of mind to routinely arrange for a chaperone. ('This is Nurse Sarah who is here to help us with the examination – is that all right?')
Body language Do not ignore any intuitive or nonverbal signals – the patient who gives a coy or ambiguous look or who seems rather excited at the prospect of an intimate examination certainly should not be seen alone.
What constitutes an intimate examination? Conventionally this is taken to be within the bikini areas.
The setting While most UK general practice has to operate pragmatically with opportunistic examinations, carried out on first presentation of symptoms, it is considered better medicolegal practice to offer an appointment for intimate examinations so that your patient does not feel pressured into consenting to an examination they may not be prepared for.
Privacy versus isolation While an intimate examination clearly needs privacy it is suggested that you should never examine patients alone inside a locked room, where they may get the impression of being isolated. Some practices even leave the consulting room door ajar to avoid this impression.
But patients should be able to undress behind the privacy of a screen, and be covered with a drape when undressed. The GMC suggests you should not assist a patient in removing clothing unless requested, and advises avoiding making any unnecessary or casual remarks during an intimate examination.
Choice of chaperone If you do not have a nurse available you may offer your patient a receptionist, though the patient must have a free choice in the matter and most patients (74 per cent) in the BJGP survey stated that receptionists were not acceptable as chaperones. Your receptionist must also be aware of issues of confidentiality. Family members – even minors – are acceptable medicolegally but should not be taken for granted as independent chaperones.
When it goes wrong Every year the medical protection societies remind us repeatedly of the importance of making good records – a declining art with the advent of computerisation – and it is good practice to record that a chaperone was accepted or refused. (Some practices set up speedkeys on the computer to record this more easily.) The chaperone's name should also be recorded.
Chaperones protect both doctor and patient from any question of the professional relationship being abused. Sadly the GMC does need to deal with such allegations – not always unfounded – regularly. Some years ago and many miles from here, I worked with a much-respected doctor – also the town's mayor – who, it transpired to our horror, was having sex in the surgery with selected patients.
On another occasion a patient with a severe mental illness spuriously alleged sexual interference by her doctor. This stressful situation was resolved on legal advice by thorough written and verbal withdrawals of the allegations, in the presence of independent witnesses.
Getting it right with the chaperone may seem a pedantic issue, but the distress and disruption caused by any allegation of inappropriate behaviour are to be avoided at all costs.
Stefan Cembrowicz is a GP in Bristol
1. Whitford, Karim & Thompson: British Journal of General Practice, May 2001,
Look at issue 4, chaperones
Medical Ethics Today (pub.BMJ Books 12/2003)