Chaperones are only part of the solution to preventing misinterpretation of a doctor's conduct, as Dr Gerard Panting explains
High profile prosecutions of doctors - usually GPs - accused of indecent assault always prompt the question Should GPs routinely use chaperones when conducting intimate examinations of female patients?'
The reflex answer is 'Yes', but that answer presumes that it is always male doctors accused of assaulting young female patients, that the examinations requiring chaperones can be neatly circumscribed and predicted, that chaperones will be universally available and acceptable to patients and that chaperones are a complete solution to the problem.
Although it is male doctors who are most commonly accused of assaulting female patients, there are many examples of alleged homosexual assault by both female and male doctors. Allegations may also be raised when a doctor conducts any form of examination, and there is no definitive cut-off age before or after which chaperones need not be considered.
In one instance, a young female patient complained of a sore throat. She complied with the doctor's request to examine her groins but later complained to the health authority that she had been assaulted. The complaint was resolved when it was explained to her that the doctor had suspected infectious mononucleosis and was checking for enlarged inguinal glands.
Clearly, it would be impractical to have a chaperone present in every consultation, and the very presence of another person in the consulting room is likely to affect the dynamics of the consultation.
Chaperones have their place but they can only be part of the solution to preventing misinterpretation of a doctor's conduct.
Many complaints of indecent assault arise from misinterpretation of the doctor's behaviour, as in the case cited above. In another case, a doctor examining a patient's central nervous system switched off the light, throwing the room into darkness, and approached the patient, who was sitting on the side of the couch, to examine her fundi with an ophthalmoscope. The patient, surprised by these events, was convinced that he was trying to kiss her - an easily avoidable embarrassment for both parties.
Preventing a complaint
The first step in preventing misunderstanding is down to communication. When any form of examination is required, the GP must explain what is proposed and obtain the patient?s agreement before proceeding. When the doctor assumes that the patient understands what is going to happen misunderstandings are likely to occur.
The idea that patients will always trust their doctors to do what is best for them without a word of explanation is out of date. In another case, an anaesthetist providing general anaesthesia for patients in a dental practice was shocked to be arrested on suspicion of rape. It was the anaesthetist's practice to give suppositories for post-operative pain relief, but he did not tell the patients in advance or afterwards. On the occasion in question, he inserted a suppository into the vagina instead of the rectum, having put his hand down the young woman's trousers and inside her knickers while she was unconscious.
The patient's subsequent vaginal discharge prompted her to report the incident to the police. Forensic tests and further investigation ensued but criminal charges were not pursued. However, the doctor and the dentist were subsequently arraigned before their respective regulatory bodies.
Privacy and modesty
When patients need to undress, they must be allowed to do so in private. Assisting patients in this can send the wrong message. If it looks as if the patient needs help, offer it, but wait until he or she accepts it. There are many examples of doctors pulling up a patient's bra to auscultate the heart something the patient may find odd if the doctor has not explained what he is doing.
When the examination is over, the patient should be allowed the appropriate degree of privacy to get dressed again.
It is important to preserve the patient's modesty during an examination as far as is reasonably possible without compromising the examination itself. It is often a combination of factors that will lead a patient to feel uncomfortable and wonder if the doctor?s conduct is entirely in line with professional norms.
Doctors must remain absolutely professional throughout -a lighthearted comment designed to help settle an anxious patient during an intimate examination may be misinterpreted, leaving the patient to believe that an ulterior motive lies behind the examination.
A clear explanation and a professional and considerate manner, combined with adequate privacy for the patient will remove the potential for misunderstanding in most cases. However, there are times when either the doctor or patient feels uncomfortable, and in these circumstances using a chaperone is one option to consider. Another would be to arrange for another doctor of the same gender to conduct the examination at a later date.
Using a chaperone
The use of chaperones raises further questions. Should the chaperone be a nurse? Is it acceptable to use a receptionist or a relative of the patient? If the examination takes place behind closed curtains, should the chaperone stand inside or outside the curtains? How can confidentiality be preserved?
Nurses do the job very well but are rarely available at a moment's notice to come into the consulting room. As their role in primary care expands, Their availability to chaperone doctors will diminish. However, there is no reason why a receptionist should not act as chaperone, provided the patient agrees. Relatives, too, may be appropriate chaperones and during home visits may be the only people available.
Confidentiality is an important issue. The chaperone should only be present for the examination itself, and the patient should be reassured that all practice staff fully appreciate their responsibility not to divulge any confidential information about patients to anybody else. Nevertheless, most of the discussion between doctor and patient should take place before or after the examination when the chaperone will no longer be in the room.
It is acceptable to use a relative as a chaperone provided, of course, that this option is acceptable to the patient. However, great care must be taken not to mention sensitive issues, especially when relatives are in the room, and as far as possible discussion should be confined to times when the relative is not present.
As to where the chaperone should stand -inside or outside the curtains essentially it is a matter of balancing discretion and the need to see that nothing untoward has taken place.
As in every other area of medical practice, determining whether or not it is appropriate to offer or suggest a chaperone is a matter of judgement. In any event, the key to avoiding misunderstanding is to communicate clearly and to avoid any behaviour that may be open to misinterpretation.