Using chaperones in remote consultations

APPROPRIATE use of chaperones should be standard in all medical practice in order to reduce the risk of accusations of inappropriate behaviour when conducting physical examinations. GMC guidance on the issue states: "When you carry out an intimate examination, you should offer the patient the option of having an impartial observer (a chaperone) present wherever possible. This applies whether or not you are the same gender as the patient".

Currently with COVID-19, an increasing proportion of consultations are being carried out remotely by video, and the Health Secretary Matt Hancock recently stated that from now on "all consultations should be tele-consultations unless there's a compelling clinical reason not to". This raises the question of how healthcare professionals can provide safe care to a patient requiring an intimate examination that would normally involve use of a chaperone. MDDUS has received numerous calls to our advice line regarding this topic, particularly in relation to whether (and when) it might be appropriate to carry out such examinations remotely and the implications on the role and use of chaperones in these circumstances.

Should you feel an examination is required during a remote consultation it is essential to consider to how best to safely arrange this. The GMC has recognised that doctors may need to depart from established procedures during the pandemic and, with that in mind, there may be a stronger argument for undertaking an intimate examination remotely during the current climate than would ordinarily be the case. GMC advice on intimate examinations and the use of chaperones does not explicitly exclude the possibility of such an examination taking place remotely, but there are obviously times when a face-to-face examination will be essential.

Faced with a patient who may require remote examination you should first discuss the limitations of the medium and consider whether it is best to defer the examination until the patient can attend face-to-face. If delaying the examination could potentially cause further harm to the patient or delay further investigation, you may decide a remote examination is appropriate. Whatever you decide, it is important to document your reasoning within the medical records.

An intimate examination would involve any exposure of the genitalia, breasts or rectum but could also include situations where a patient is required to undress or might otherwise feel uncomfortable. A chaperone involved in a remote consultation must be able to fulfil their role in reassuring the patient and raising any concerns about potential inappropriate behaviour by the doctor. The chaperone should be present during the entirety of an examination. Patients should be given (virtual) privacy to undress and dress and should be advised to keep covered as much as possible.

Consideration should also be given to logistical, technical and security issues involved in a chaperone joining a remote consultation as a third party should it not be possible to be physically present alongside you. For patient consent to be valid, it is important to make sure the conversation is tailored specifically to the circumstances of the remote examination. The clinician should again ensure and document that the patient is fully aware of the limitations of continuing with an examination during the video call. Check that the patient is comfortable with their surroundings/privacy and that there is no other unwanted third party present or likely to overhear/interrupt the call.

The need for a chaperone will obviously depend on the circumstances. For example, an unusual skin lesion on the shoulder might not require the patient to undress fully and may be suitable for the GP (depending on the connection, lighting etc) to quickly check over a video call. However, with a skin lesion on the breast needing immediate examination (rather than deferral for a face-to-face appointment), the patient should be adequately consented and given the opportunity to have a chaperone present during the video call.

Should the offer a remote chaperone be declined then the examination can take place on that understanding, but it is essential that the discussion is accurately recorded in the notes. Should you desire the presence of a chaperone but the patient refuses, you must explain your position clearly – ultimately the patient’s clinical need will take precedence. You may wish to consider referring the patient to a colleague who would be willing to undertake their own clinical assessment, but only if the delay will not adversely affect the patient’s health.

In view of the practical difficulties in arranging for an effective chaperone for remote intimate examinations, the MDDUS generally recommends that doctors consider a face-to-face consultation instead. However, there will be circumstances in which it is in the best interests of your patient to undertake a remote intimate examination. In these cases, we suggest you develop a robust protocol in advance, ensuring both you and your patient feel comfortable with the consultation.

Generally, there should be no requirement to video record and store a remote intimate examination. However, if you are planning to keep a recording it is essential that your patient consents in advance and you have a clear policy for how the recording will be stored and processed.

ACTION POINTS

• Follow GMC guidance on intimate examinations and chaperones and in relation to remote consulting.
• Remote examination may be the most appropriate action if delay could potentially cause further harm to the patient.
• Ensure you document any discussion about chaperones and the outcome in the patient’s medical record. If a chaperone is present, you should record their identity.
• Where a physical examination in person is required, chaperones (like clinicians) should follow up-to-date public health guidance on use of PPE to protect both themselves and the patient.

FURTHER GUIDANCE

• MDDUS Coronavirus Hub > Medical Advice > FAQS on remote consulting
• GMC Intimate examinations and chaperones 
• GMC Coronavirus: Your frequently asked questions > Remote consultations

Kay Louise Grant is a risk adviser at MDDUS