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Probity

“Probity requires that the doctor’s conduct at all times justifies patients’ trust and the public’s trust in the profession.”

(Segen’s Medical Dictionary (2011) medical-dictionary.thefreedictionary.com)

A medical professional is expected, by his colleagues and society, to be a person who can be trusted to act with integrity at all times

The term “professionalism” is so widely applied nowadays that its currency has been debased. In many people’s minds the word “professional” can be applied to any skilled worker, and “professionalism” to skilled work of any kind.

However, for the older professions (with the possible exception of the oldest of them all), “professionalism” goes far beyond the mere exercise of skill; indeed, it extends beyond the workplace and into one’s private life. A medical professional is expected, by his colleagues and society, to be a person who can be trusted to act with integrity at all times.

“Integrity is generally defined as wholeness, honesty and ‘uprightness’, being in sound and intact condition; undamaged, untainted. Your professional integrity is a measure of the degree to which your own professional reputation and credibility remain intact. It is more than just clinical or technical excellence alone, since a major element of a person’s integrity derives from the way in which they are viewed by others. Anything which has the potential to reduce a professional person’s reputation in the eyes of another undermines their professional standing.”9 (See Box 10 for examples.)

Box 10: Examples of unprofessional conduct

  • Making misleading or false claims about your practice
  • Touting for business
  • Succumbing to inducements to provide services to patients that are not clinically indicated
  • Accepting perverse incentives
  • Over-charging patients
  • Fraudulently claiming for services that have not been rendered
  • Lack of transparency to patients about financial interests in healthcare facilities or pharmaceuticals
  • Impeding patients who wish to seek a second opinion
  • Sexual impropriety, particularly with patients
  • Involvement in criminal activities
  • Continuing to practise when impaired
  • Not reporting impaired colleagues
  • Not reporting unethical behaviour on the part of colleagues
  • Engaging in medical research without the approval of an ethics committee
  • Anything that undermines public confidence in the profession
  • Anything that undermines the reputation or standing of the profession

(List derived from HPCSA guidance)

Chaperones

While their role is ostensibly to reassure patients, chaperones also protect doctors from false allegations of sexual abuse. You should, therefore, out of respect for the patient and for your own protection, always offer a chaperone when you intend to carry out an intimate physical examination, even if you and the patient are the same sex. Intimate examinations include examination of the breasts as well as the genitalia and rectum.

The issue of chaperonage is not always straightforward. For example, many patients reject the offer of a chaperone because they find it embarrassing to have another person present during an intimate examination. In most cases this is not a problem – just record in the patient’s notes that a chaperone was offered and the patient declined the offer.
Record in the patient’s notes that a chaperone was offered and the patient declined the offer

Sometimes, though, you may feel that it is personally risky for you to proceed without a chaperone present. Although this is a difficult situation to deal with (to insist on a chaperone implies that you distrust the patient), you should trust your instincts and simply tell the patient that, because of the nature of the examination, you would prefer a chaperone to be present. If the patient still refuses, then you must decide whether to proceed without a chaperone or to suggest that the patient see another doctor.

Such decisions are not an easy judgment call, but you should be particularly wary of carrying out an unchaperoned intimate examination if the patient has any of the following problems:

  • a history of sexual abuse
  • apparent difficulty in recognising professional boundaries
  • mental impairment
  • mental instability.
If you do decide to go ahead, be scrupulous in your documentation

If you do decide to go ahead, be scrupulous in your documentation.

In all cases, you should explain carefully to the patient what the examination entails and why it is necessary. You should also take care to preserve the patient’s dignity and privacy by the use of gowns, drapes and screens.

If a chaperone is present during an examination, record their identity and status in the patient’s notes. If you offer a chaperone, and the patient declines, you should record this fact too.

Ideally, the chaperone should be someone with clinical training, such as a nurse. If no clinically trained assistant is available, it may be necessary to use a member of the patient’s family as a chaperone, but this is far from ideal.

If a suitable chaperone is not available, you will have to make a judgment as to whether the examination can be postponed until appropriate arrangements can be made. In an emergency you may have to proceed without a chaperone. If so, record your decision and the reason for it in the patient’s notes.

You may sometimes find yourself seeing patients when no-one else is present on the premises at all. Although this is a less than ideal situation that you should avoid if at all possible, you should place your patients’ needs first.

In an emergency you may have to proceed without a chaperone. If so, record your decision and the reason for it in the patient’s notes