Maintaining professional boundaries in doctor-patient consultations has never been more difficult. Consultations now require more detailed discussions with ever-more informed patients, who also have increased control over managing their own care. Since 2004, in the wake of the Clifford Ayling case, the Committee of Inquiry has upheld the following recommendations regarding the provision of chaperones:
- Every trust or practice must have a chaperone policy available to patients,
- Every trust or practice must have an appropriately-trained managerial lead,
- Family members or friends cannot undertake the chaperone role,
- Chaperones must receive appropriate training,
- Chaperones must be present/not present at the behest of the patient.
What Is a Chaperone?
A chaperone is a trained independent observer of examinations and procedures, whose presence is designed to maintain a healthy doctor-patient relationship. The GMC’s ‘Good Medical Practice’ guidance on chaperones states that a chaperone should usually be a health professional, and that a patient must feel confident that their chaperone will
- be sensitive and respect the patient’s dignity and confidentiality;
- reassure the patient if they show signs of distress or discomfort;
- be familiar with the procedures involved in a routine intimate examination;
- stay for the whole examination and be able to see what the doctor is doing, if practical; and
- be prepared to raise concerns if they are concerned about the doctor’s behaviour or actions.
The chaperone’s details should be recorded in the clinical record, and the patient informed that the details have been taken.
When Is a Chaperone Offered?
Chaperones must be offered before a patient undergoes an intimate examination, but the definition of an intimate examination may vary by patient. Chaperones may also be offered for specific parts of a consultation, as well as for entire meetings, or examinations. It may also be beneficial to have a chaperone present if a patient is
- being seen by a trainee or students,
- of a different culture,
- being rotated through surgeries by the CCG,
- known to be difficult, or to have had differences with their physicians in the past.
A chaperone must be properly positioned to observe the procedure, and therefore to act as an independent witness as to how the examination was carried out.
What Is an Intimate Examination?
An intimate examination is any examination that may be distressing or embarrassing for a patient. These most commonly include examinations of the rectum, genitalia, breasts, or other examinations involving touching or close proximity – such as eye examinations or applying blood pressure cuffs.
Why Are Chaperones Needed?
Chaperones protect both doctors and patients from inappropriate behaviour and false allegations, and ensure that a patient’s dignity is preserved. They provide emotional comfort and acknowledge the vulnerability of all patients and may assist with the examination or undressing of patients as required.
Practices should use trained chaperones, rather than practice staff to fulfil the role of chaperone. They don’t necessarily have to be medically qualified, but they must be
- a health professional,
- sensitive to confidentiality,
- able to reassure,
- familiar with the procedures demonstrated in the examination they are observing, and
- prepared to raise concerns about a doctor.
What If a Chaperone Is Not Available?
If a chaperone is not available – if an examination is due to take place out-of-hours, for example – then doctors should consider whether the examination they are about to undertake is urgent or not. If not urgent, then the most appropriate course of action would be to arrange the examination for a time when a chaperone will be available. In the event that the patient will almost inevitably need admission to hospital, it might be more appropriate to defer examination until after admission. If the examination is urgent, then the patient can give written consent and the examination may have to take place without a chaperone. Full records of procedures should be made.
Information on the chaperone policy should be freely available to patients, and when offering chaperone provision to patients, the following points should be addressed:
- Establishing the need for an examination with the patient;
- Giving the patient the opportunity to ask questions;
- Obtaining and recording patient consent;
- Explaining why a doctor may wish a chaperone present if an examination is intimate;
- Recording reasons for a chaperone to be declined;
- If the patient refuses a chaperone, decide whether to precede with the examination or not;
- Respecting cultural differences, especially religious reasons which may affect the decision to have a chaperone present;
- Giving a patient privacy to undress, and the potential use of drapes;
- Explaining step-by-step the process of the examination;
- Recording the chaperone’s identity;
- Keeping the presence of the chaperone to a minimum necessary period;
Declining a Chaperone
Even if a patient chooses to not have a chaperone present, a doctor or nurse may still feel that a chaperone would be wise – for a genital exam of an adolescent of the opposite gender, for example. In this instance, the doctor or nurse should explain that a chaperone would fulfil their role of assisting with the procedure and reassuring them. It is also important to understand why the patient has declined a chaperone, and to alleviate any concerns they may have.
Another option, if the patient continues to decline a chaperone, is to ask a colleague to undertake the examination on your behalf. This may alleviate some gender appropriateness issues, but the chaperone issue may still persist. Referral to a secondary care facility may also be an option.
Doctors intending to inform their patients of the chaperone policy should also record all interactions regarding the chaperone in the patient’s medical records. All chaperones should also be fully trained, and doctors are not required to conduct examinations if the offer of a chaperone is declined. There should always be a focus on respecting the diverse backgrounds of patients, and examinations should only go ahead if there is no language, communication, or consent barrier.