Chaperones: A safeguard for both doctor and patient

Ms Claire Cregan explains the benefits of chaperones for physical examinations, particularly those of an intimate nature

Trust is the foundation of the patient-doctor relationship. Patients should be able to trust that their doctor will behave professionally towards them; this is of particular importance where clinical assessments involve intimate examinations of patients. Intimate examinations include examinations of breasts, genitalia, and rectum; however, this list is not exhaustive and it is vital that doctors are cognisant of their professional and ethical obligations regarding such examinations. It is also important to bear in mind that what might be categorised as intimate may well depend on the individual patient and their vulnerabilities. Each doctor must have regard to the individual patient and their circumstances, including age, gender identity, and cultural background, and consider whether it is appropriate to offer a chaperone, who can act as a safeguard for both the doctor and the patient during an intimate examination.

Intimate examination

Intimate examinations can be uncomfortable and often embarrassing for patients, and it is vital that patients are made to feel as safe and at ease as possible in the circumstances. The ninth edition of the Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (the ‘Guide’), which was published earlier this year, provides guidance on this subject. It states, before undertaking any physical examination, including an intimate examination, you should discuss this with the patient, explaining why it is needed, what will be involved and addressing any concerns that the patient may have, and obtain consent. The Guide further provides that 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, according to the document. It further states that you must not carry out intimate examinations on anaesthetised patients unless the patient has given explicit (usually written) consent to this in advance.

The matter of consent is beyond the scope of this article, but it is important to be aware that you must obtain informed consent from the patient, or have another lawful authority, before initiating any treatment, which includes any examination or investigation. Consent for intimate examinations must be documented in the patient’s medical record. By way of reminder, the term “you must” is used throughout the Guide where there is an absolute duty on the doctor to comply with the guidance that follows. The term “you should” is used to describe best practice in most circumstances, accepting that it may not always be practical to follow the guidance or that another approach may be appropriate in particular circumstances. A doctor should exercise their judgement in such cases.

As mentioned, 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; this may be particularly true of vulnerable patients or those who have suffered abuse. For patients with certain cultural or religious beliefs, this can be an extremely sensitive situation and it is therefore important that doctors use their clinical judgement on each occasion and offer a chaperone where appropriate, irrespective of the gender of the patient or the doctor. 

Chaperones

In a clinical setting, a chaperone can be described as an independent person, acting as a witness for both a patient and a healthcare provider, as a safeguard for both parties during a medical examination or procedure, where the patient may need to undress and have examination or care of intimate areas of their body (Children’s Health Ireland, Guideline on Chaperone Care, November 2021).

Where a doctor deems an intimate examination to be clinically appropriate, they “should” ask the patient if they would like a chaperone to be present and record their wishes, according to the Medical Council’s Guide. Of note, the previous edition of the Guide, (eighth edition) stated that where an intimate examination is necessary, “you must” ask the patient if they would like a chaperone to be present. This absolute duty did not carry through to the updated Guide but, as previously discussed, the term “you should” describes best practice. The doctor should clearly explain to the patient what role the chaperone will have during their examination.

Where a chaperone has been used, they should leave the room following the examination; there is no need for them to be present for any subsequent discussion of the patient’s condition or treatment. It is also recommended that the doctor records the chaperone’s identity, including their job title, in the patient’s clinical records. If, at a later date, an allegation of inappropriate behaviour was made against the doctor, it is important to have a clear record of who acted as chaperone during the examination.

If a chaperone is not available, the doctor should confirm if the patient wishes to proceed or make alternative arrangements, as long as the delay would not adversely affect the patient’s health, according to the Guide. In these circumstances, the doctor should consider whether the examination is urgent and necessary. If it is not urgent and the patient requests a chaperone, it is advisable to reschedule the appointment for a time when a chaperone is available. Where possible, doctors should make reasonable efforts to ensure the availability of a chaperone at certain times in the working week, to offer to patients where intimate examinations are required.

Where a patient declines a chaperone, in some cases the doctor may feel it would be more prudent to have one present 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; this is a personal decision that the doctor will need to make exercising their own clinical skills and judgement. Where a doctor decides to proceed in the absence of a chaperone, they should carefully document in the patient’s records that a chaperone was offered and declined by the patient.  

If electronic records are used, it may be of assistance to have a chaperone template to record the patient’s relevant decision. It may be helpful to liaise with a software provider to put in place relevant templates on the system. It is also advisable for a doctor to develop a chaperone policy for their clinic/organisation and consider displaying this policy on their website and/or in their waiting room via a poster, for example. This can assist in encouraging patients to ask about a chaperone prior to their examination.

Who should act as a chaperone?

The Guide does not provide specific guidance on who should act as a chaperone during intimate examinations. It is advisable; however, that a healthcare staff member who understands what the examination involves, should act as a chaperone where intimate examinations are being undertaken. A trained chaperone may feel more comfortable raising questions or concerns about how the examination was conducted, and if necessary, they can confirm the examination was carried out appropriately. Where possible, it is advisable to use a chaperone of the same gender as the patient.

If non-medical staff members are to undertake the chaperone role, eg, a receptionist/administrative staff member, they should be fully trained. Training should ensure familiarity with the procedure, where to stand during the examination so they can see the patient and the process of the examination, how to raise concerns about a doctor if misconduct occurs, as well as training in maintaining patient confidentiality. It is advisable that family members or friends of either the patient or the doctor should not undertake the chaperoning role as they may not fully appreciate the nature of the physical examination and may not be completely impartial. If a patient indicates that they would also like a support person present for the examination, which is likely to be a family member or a friend, a doctor should facilitate this request where practicable.

Conclusion

A key focus in all clinical encounters should be an evaluation of whether to use a chaperone for some or all physical examinations, particularly intimate examinations. This should be considered regardless of the gender of the patient or the doctor, and irrespective of the long-term nature of the doctor-patient relationship and having regard to professional and ethical obligations as set out in the Guide and discussed above. Ultimately, a chaperone can offer protection for the doctor, as well as reassurance for the patient, and it is vital that doctors exercise their clinical judgment on each occasion where an intimate examination is indicated.

References available on request