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Someone to watch over me

Dr Ming-Keng Teoh, Head of Medical Services (Asia), and Gareth Gillespie reiterate the importance of using chaperones

Modern-day healthcare goes beyond providing appropriate care to patients; managing relations with patients, developing trust and respecting professional boundaries needs almost as much consideration as making the correct diagnosis or safe prescribing.

MPS has always strongly advocated the role of good communication in the doctor–patient relationship – partly because of the frequently-quoted figure that 70% of litigation is related to poor communication following an adverse event1 – and one way of establishing an instant empathy with your patient is to show that you respect his/her needs and privacy – which includes being aware of when to use a chaperone.

Offer a chaperone to all patients for intimate examinations, or examinations that may be construed as such

How to use a chaperone

Offer a chaperone to all patients for intimate examinations (or examinations that may be construed as such):

  • Establish that there is a need for an intimate examination and discuss this with the patient.
  • Explain why an examination is necessary and give the opportunity to ask questions; obtain and record the patient’s consent.
  • If the patient does not want a chaperone, record this in the notes. 
  • If the patient declines a chaperone and as a doctor you would prefer to have one, explain to the patient that you would prefer to have a chaperone present and, if they decline, you can decline to treat them. 
  • Explain what you are doing at each stage of the examination, the outcome when it is complete and what you propose to do next. Keep the discussion relevant and avoid personal comments. 
  • Record the identity of the chaperone in the patient’s notes. 
  • Record any other relevant issues or concerns immediately after the consultation. 
  • In addition, keep the presence of the chaperone to the minimum necessary period. There is no need for them to be present for any subsequent discussion of the patient’s condition or treatment.

What not to do

  • Allow a relative or friend of the patient to be a chaperone, as they may not fully appreciate the nature of the physical examination performed. 
  • Allow one of your relatives to be a chaperone. They may not be an impartial observer and could have a biased opinion.

The following MPS case study shows how a complaint could have been avoided if a chaperone had been present:

Case 1: “No time” – No excuse

Miss C saw GP Dr N with symptoms of cough, runny nose, sore throat and headache, which she had for three days. Dr N examined her while she was sitting down in an upright position. He diagnosed an upper respiratory tract infection.

Just as the consultation was coming to a close, Miss C mentioned some abdominal pain. Dr N asked that Miss C lie on the bed for examination.

He then carried out an abdominal palpitation and auscultation; however, when he began to listen to Miss C’s chest, Miss C became uncomfortable and shifted away. She queried why the examination had moved to her chest when her pain was in her abdomen.

Dr N did not have a chaperone present, which he put down to having a busy day. Dr N had to explain himself before the Medical Council

Later, Miss C made a complaint to the Medical Council. Dr N did not have a chaperone present, which he put down to having a busy day. Dr N had to explain himself before the Medical Council and issued a formal apology to Miss C.

Learning points

The presence of a chaperone would have enabled Dr N to quickly explain the reason for and nature of his examination. The Medical Councils in Hong Kong, Singapore and Malaysia all recommend the use of a chaperone when conducting intimate examinations.

In Singapore, any instance of a male doctor examining a female patient should be attended by a female chaperone, while in Malaysia the guidance states that a chaperone should be present during all examinations, regardless of sex or age of the patient. See Box 1 for the relevant extracts from their guidance.

Conducting the examination

When you are carrying out a physical examination on a patient, you should explain fully what you intend to do and why you have to do it, and offer the patient the option of having a chaperone present. If the patient declines the use of a chaperone, you should record this decision in the medical records. These discussions are for the protection of both the patient and the doctor, and are particularly important.

If the patient declines the use of a chaperone, you should record this decision in the medical records

A doctor should avoid making personal comments or attempts at humour during an examination. The patient should also be given privacy to undress and dress. Remember that allegations of improper conduct can relate to, or arise from, improper comments during the consultation and misconstruing the doctor’s actions – not just from an intimate physical examination.

The following case, which was handled by MPS, demonstrates how the presence of a chaperone protected the doctor from further action – although other aspects of his communication fell short.

Case 2: Left in the dark

Locum GP Dr T was carrying out his first shift at a city practice. Patient Miss W attended for a pre-employment health screening. Dr T ensured a chaperone was present and carried out the examination, which included breast and genitalia examinations.

Miss W returned to the practice two days later, complaining that she had been “violated” by Dr T. She claimed that her friends had attended the same practice for their pre-employment screening, and they were not required to have a breast or genital examination. Dr T reiterated that he was following the guidance set out in the pre-employment health screening protocol.

Dr T later admitted to not having sufficiently explained the procedure to Miss W, or obtained her consent to proceed with the examination

However, Dr T later admitted to not having sufficiently explained the procedure to Miss W, or obtained her consent to proceed with the examination. MPS assisted Dr T in issuing an explanation and apology to Miss W, and no further action was taken.

Learning points

Although Dr T correctly ensured a chaperone was present during the examination, he failed to ensure that informed consent was taken from Miss W. For consent to be fully informed, a patient must always have the examination or procedure sufficiently explained, and be given the opportunity to ask questions.

When a complaint arises that requires an explanation and clarification, it is important to do so in a caring and open manner. Be prepared to address all the patient’s concerns.

It is always the responsibility of the doctor to manage professional relations with patients, regardless of their attitude or level of expectation.

While utilising a chaperone effectively isn’t an omnipotent safeguard from complaints and claims, it can provide significant protection and assistance in some sensitive situations. More importantly it signifies awareness and respect of your patient’s needs, which is an important building block in a trusting doctor–patient relationship.

Box 1: The official guidance

Medical Council of Hong Kong, Professional Code and Conduct for the Guidance of Registered Medical Practitioners (2009)

An intimate examination of a patient is recommended to be conducted in the presence of a chaperone to the knowledge of the patient. If the patient requests to be examined without a chaperone, it is also recommended to record the request in the medical records.

Malaysian Medical Council, Duties of a Doctor: Good Medical Practice (2001)

A doctor must always examine a patient, whether female or male, or a child, with a chaperone being physically present in the consultation room, with visual and aural contact throughout the proceedings.

A relative or friend of the patient is not a reliable chaperone, as he or she may not fully appreciate the nature of the physical examination performed by the doctor and may even testify against the doctor in the event of allegations of misconduct or physical abuse. More importantly the patient may have a need for confidentiality or could well be embarrassed by having a close family or friend witness an intimate examination. Similarly, a relative of the doctor (wife, daughter, etc), who is not an impartial observer, could be prejudicial as a chaperone. These requisites are designed to allow the doctor to proceed with clear, unhampered clinical examination of the patient, as he deems appropriate for the purpose of arriving at a proper diagnosis, without later having to defend his actions.

Singapore Medical Council, Ethical Code and Ethical Guidelines (2002)

Patients shall be treated with courtesy, consideration, compassion and respect. They shall also be offered the right to privacy and dignity. It is recommended that a female chaperone be present where a male doctor examines a female patient. This will protect both the patient’s right to privacy and dignity, as well as the doctor from complaints of molestation.

References

  1. Beckman HB, Markakis KM, Suchman AL, Frankel RM, The doctor–patient relationship and malpractice: lessons from plaintiff depositions, Arch Intern Med154:1365-70 (1994)
1 comment
  • By Jujubean on 17 October 2016 08:30 A chaperone should be OFFERED , not forced on a patient whether they want one or not. Also they should not be where they can see the patients from the most revealing angle. You don't HAVE to see the patients junk to know if the doctor has gloves on if he is forcibly holding the patient down or if she has asked him to stop but he wouldn't.
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