Reducing risk: do you offer a chaperone?

A recent MDDUS case highlighted the importance of offering patients a chaperone for intimate examinations, regardless of the gender of patient or doctor.

In this case, a rectal examination was carried out by a male GP to assess the patient’s prostate gland after the patient described a number of concerning symptoms. The GP had been careful to inform the patient that both abdominal and rectal examinations would be required. He explained the procedures for these and asked the patient to get on the couch. The patient duly obliged and, following both examinations, a management plan for further follow-up was agreed.

The consultation had seemed to go well and it was only a couple of weeks later, when a letter of complaint arrived at the practice, that the patient’s concerns about a lack of chaperone came to light.

Thankfully, in this particular case, there is no suggestion that the manner in which the GP carried out the clinical examination was in any way inappropriate. However, the patient has raised valid concerns about deficiencies in practice in relation to regulatory guidance.

The patient complained that (1) the GP should have obtained his explicit consent to an intimate examination and (2) the GP should have offered him the option of having a chaperone present for the intimate procedure.

Both points raised by the patient are clearly covered within the GMC’s guidance for doctors, Intimate Examinations and Chaperones (2013):

Point 1: OBTAIN CONSENT

The GMC states:

5c. get the patient’s permission before the examination and record that the patient has given it

In this case there is no record of the patient giving permission for a rectal examination to be undertaken. The GP regarded the patient climbing onto the examination couch as giving implied consent.

Point 2: OFFER A CHAPERONE

5d. offer the patient a chaperone

8. 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.

13. You should record any discussion about chaperones and the outcome in the patient’s medical record. If a chaperone is present, you should record that fact and make a note of their identity. If the patient does not want a chaperone, you should record that the offer was made and declined.

In this case a chaperone was not offered. The requirement of a chaperone not considered.

Is normal practice risky practice?

Reviewing this case made me stop and think.

There has been GMC guidance on using chaperones when carrying out intimate examinations for some years now and yet I wonder whether GPs have incorporated this guidance into their day-to-day practice. Certainly anecdotally, in talking to groups of GPs about the risks associated with intimate examinations, their practices around chaperones are variable.

Reasons given to me for why chaperones are not always offered have included:

1. the perception that patients might be further embarrassed by the offer of a chaperone
2. the perception that ‘same gender’ examinations in particular are low risk (see above, the GMC guidance is that chaperones should be offered whether you are of the same gender or not)
3. the perception that females encounter fewer allegations of improper practice than males (indeed a 2009 survey carried out by the BMJ found that significantly more males than females offer chaperones)
4. concerns about the time that utilising a nurse or trained non-clinical chaperone would take in the midst of busy surgeries
5. concerns that if all patients who require an intimate examination were offered one, this would impact significantly on staffing levels

MITIGATING RISKS

It’s true that if every patient who had to have an intimate examination took up the offer of a chaperone, this would impact significantly on the day-to-day working of a practice. Results within a 2010 study published in the BMJ indicate that the offer of a chaperone would be accepted in less than 5 per cent of instances offered.

Where there is no offer made though, GPs expose themselves to the risk of complaint to the police of sexual assault, a GMC complaint and subsequent investigation, or worse a malicious allegation of inappropriate examination (although this is less likely).

I am really interested to hear your own experiences in relation to offering and using chaperones. For those of you who do offer a chaperone for all intimate examinations, it would be great to get a feeling for what the real impact has been on your resources.

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Click here to access our new MDDUS checklist for reducing risk by effective use of chaperones