Up close and personal

DOCTORS are routinely required to examine the most intimate areas of a patient’s body and it is something that can quickly become routine.

But while it may be an everyday common occurrence for GPs, this kind of medical attention can often be embarrassing or distressing for patients. And unless doctors are careful to fully explain how an intimate examination will be conducted and gain informed consent, there is a risk they could find themselves the subject of a patient complaint. Consider the following scenario:

It was a routine consultation for a repeat prescription for the contraceptive pill. The computer screen flagged up that this Polish lady was due a smear test so, to save time, I decided to take the smear sample myself rather than have her come back. I advised her she was due a smear test and asked if she would mind if I did it during the consultation. She nodded and lay down on the examination couch. Her record indicated she had had a smear before so I didn’t foresee any problems. I took the smear without difficulty but it was only afterwards that I noticed something was wrong. Her eyes filled with tears as she told me she hadn’t realised what I had asked her, that she had not wanted this examination and would be writing a letter of complaint about me to the practice manager. I was shaken by this, after all I was only trying to help her and stop her having to come back. I had her best interests at heart, so surely I had done nothing wrong?

Consent

The principle that “every person has the right to have his bodily integrity protected against invasion by others” has long been recognised in common law and has been defined in case law in many jurisdictions, perhaps most classically by Justice Benjamin Cardozo in his 1914 ruling in New York:

“Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without the patient’s consent commits an assault.”

When considered in these terms, it is clear why the process of securing informed consent is so vitally important in medicine, not only for the patient’s benefit but also to protect the doctor from any accusations of wrong-doing.

For consent to be valid it must be informed, competent and freely given. It must then be recorded, clearly and contemporaneously, in the medical notes. The General Medical Council provide more detailed information in their core guidance Good Medical Practice (paragraph 36) and in supplementary guidance Seeking patients’ consent: The ethical considerations. Failure to follow this guidance, particularly in intimate examinations, could put your registration at risk so it is essential you familiarise yourself with it.

Intimate examination

So what constitutes an intimate examination? Most people would agree this is likely to include examination of the breasts, genitalia and rectum, but definitions can vary from patient to patient. In some cases, a patient may perceive an intimate examination as one where the doctor touches them or even moves close to them. A patient’s culture or belief system can influence their views of intimate examinations and it is worth reading the GMC guidance Personal Beliefs and Medical Practice for more information.

Another GMC guidance document that is useful when considering intimate examinations is Maintaining Boundaries. This emphasises the doctor’s duty to explain why the examination is required in a way the patient can understand and to allow them to ask questions before beginning the examination. It also stresses the need for doctors to take and record the patient’s consent. When undressing, the patient should be given privacy and during the examination you should try to keep them covered as much as possible to maintain their dignity. It is not appropriate to help the patient undress unless they have specifically asked for your assistance.

During the examination it is important to keep explaining what you are doing and ask permission from the patient if this differs from what was originally agreed. It is okay to chat to the patient to make them feel at ease but keep the conversation relevant and avoid making any unnecessary comments which may be open to misinterpretation. You should also be prepared to stop the examination if the patient asks you to.

Chaperones

Before carrying out an intimate examination, it is important to ask the patient if they would like an impartial observer to act as a chaperone during the consultation. This applies whether or not you are the same gender as the patient.

The chaperone does not have to be medically qualified but should be sensitive and respectful of the patient’s dignity and confidentiality. He or she should be prepared to reassure the patient if they show signs of distress or discomfort and be familiar with the procedures involved in a routine intimate examination. The chaperone must also be prepared to raise concerns about a doctor’s behaviour where necessary. In some circumstances a member of practice staff or a relative or friend of the patient may be an acceptable chaperone.

It is important that any discussion about a chaperone is noted in the medical record, including the chaperone’s name. If the patient does not want a chaperone and you are happy to proceed, then it should be noted that a chaperone was offered and declined. If either the doctor or patient does not wish the examination to proceed without a chaperone or either party is uncomfortable with the choice of chaperone, you can offer to delay the examination until a suitable chaperone is available. Any decision that is made should take into account the patient’s best interests.

A failure to communicate

Let’s return to the scenario. It is easy now to see that the consent taken in this case was not informed. The doctor failed to adequately explain what she intended to do and instead relied on the assumption that the patient, having previously had a smear test, would understand what she was talking about. Importantly, the doctor also failed to check the patient understood what she had been told. It was also extremely remiss for the doctor not to offer the patient a chaperone.

It is not uncommon for GPs to consult with patients who speak little or no English. In these cases, it is the doctor’s duty to ensure arrangements are made to meet the patient’s language and communication needs. An interpreter can usually be arranged in advance through your health board or PCT.

In the scenario, the fact this patient is Polish should have prompted the doctor to be especially vigilant in checking her understanding. Beware the patient who smiles and nods but actually has very little understanding of what is being said. Check frequently that patients do understand fully what you are saying and, if in doubt, offer to organise an interpreter or ask them to return with an appropriate person who can assist at the review appointment. This is especially important when it comes to intimate examinations where the potential for misunderstanding is great and can lead to very serious consequences for the doctor.

Hopefully after reading this article you will not make the same mistakes, but please do not hesitate to contact MDDUS for advice if you are ever in any doubt.

Dr Susan Gibson-Smith is a medical adviser at MDDUS