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Silent witness

Sara Williams explores how using chaperones for particular consultations can protect your practice

The challenge for today’s doctors is to show their human face while maintaining clear professional boundaries. Using a chaperone is not only an effective safeguard against unfounded accusations; it will help put a patient at ease.

Respect for a patient’s autonomy is expressed in many different ways. On an overt level, it is conveyed by seeking consent, conducting open discussions and working in partnership with patients. On a more subtle level, it requires a sensitive recognition of the power differentials that exist between doctors and their patients, and the vulnerability patients may feel.

Using a chaperone is both an added layer of protection and an acknowledgement of a patient’s vulnerability. The Code of Health and Disability Services Consumers’ Rights provides that: “Every consumer has the right to have one or more support persons of his or her choice present, except where safety may be compromised or another consumer’s rights unreasonably infringed.”1

Defining the third person

For particular consultations, doctors may want another person present. The role they will play will depend on the individual circumstances of the consultation. The function of the third person should be clearly understood by all parties, so it is necessary to obtain informed consent beforehand. A third person may be present to participate in one of the following five roles as defined in this statement:

  • A support person for the patient – Patients have the right to request one or more support people for consultations that might cause discomfort or confusion. Their presence focuses on the needs of the patient.
  • An interpreter for the patient – This is the patient’s right under Right 5(1) of the Code of Health and Disability Services Consumers’ Rights. An interpreter may assist with translating a different language or with the understanding of someone with a disability or alternative form of communication (ie, sign language).
  • An observer for the doctor – This person is present at the doctor’s request for a number of reasons, eg, part of CPD to assess the doctor.
  • A student or trainee – Participation in teaching is covered by the Code of Health and Disability Services Consumers’ Rights. If a student or trainee is present during a consultation, an explanation should be provided before the consultation and consent obtained.
  • The doctor’s chaperone – A chaperone is a person who, at the invitation of the doctor and with the patient’s informed consent, is present during a specific examination or treatment procedure. This could be part of an internal practice policy.2

If a patient or doctor refuses the attendance of a third person, they have the right to withdraw from the consultation until a mutually acceptable third person is available. Alternatively, the patient may be referred to another doctor.

Using chaperones

“The use or offer of a chaperone should be routinely annotated in the clinical record, even if this is declined by the patient (eg, COD – Chaperone offered: declined, or CP – Chaperone Present).”3

The use of chaperones should not be restricted to male doctors and female patients, or when a physical or internal examination is carried out. Be aware of grey areas of vulnerability where an inadvertent breach may occur. Examples include listening to the chest, taking the blood pressure cuff and palpating the apex beat – all could involve touching the breast area.

When choosing a chaperone, consider that: 

  • Chaperones should have the knowledge to assess the appropriateness of an examination and/or procedure as well as the way in which an examination and/or procedure is carried out.4
  • Receptionists are not generally considered acceptable.
  • The most appropriate person would be a member of the clinical team, but the patient must be introduced to them and told what their position is beforehand. 
  • Potential inadvertent breaches of confidentiality make friends and relatives poor choices of chaperones.
If a patient or doctor refuses the attendance of a third person, they have the right to withdraw from the consultation until a mutually acceptable third person is available

Doctors with conditions on registration

Some doctors have conditions on their registration that require a chaperone to be present at certain types of consultation. Doctors who have this condition on their practice should inform their employer of the condition, as it is usually the result of past disciplinary action.

Doctors who have chaperone conditions should disclose the reason behind the requirement if they are questioned by a patient
For such doctors, the presence of a chaperone is not optional and if a patient does not feel comfortable, they should be referred to another doctor. According to the Medical Council of New Zealand, doctors who have chaperone conditions should disclose the reason behind the requirement if they are questioned by a patient. The only exception to the chaperone condition is in an emergency situation. A doctor with a chaperone condition may attend an emergency, even when a chaperone cannot be located.

Summary

There is a real risk in practice of patients mistaking your intentions, so respectful two-way communication and the judicious use of chaperones are your best protection from false or unfounded allegations.

Scenario A

Locum GP Dr A is seeing a patient, Miss F, who is complaining of a problem in her right eye. Dr A explains that “he will need to look at the back of the eye”. He promptly turns out the light in the consulting room and proceeds to perform a fundoscopy.

Whilst Dr A is leaning forward, his tie inadvertently (and unbeknown to Dr A) comes into contact with Miss F’s blouse. She leaves the consultation thinking that Dr A has touched her inappropriately and makes a complaint.

She leaves the consultation thinking that Dr A has touched her inappropriately and makes a complaint

Advice 

Dr A should have given a clear explanation as to what the examination entailed and confirmed the patient was content for him to proceed before going ahead. Inadvertent contact of this nature can easily be misconstrued, especially in this particular context. Dr A should have been alive to this possibility and taken reasonable steps to minimise such risks (for example, by explaining why he turned the light out, why he had to be so close and tucking his tie in). If any inadvertent contact does occur during the course of an examination, an apology and an acknowledgement should be offered immediately.

Key points

  • Third person policies should be displayed in the practice waiting and examination areas.
  • Arrangements for the presence of a third person should be in place prior to the start of the consultation. 
  • All parties involved in the consultation must understand the role of the third person, and the patient must give informed consent for a third person to be present and the role they will take. 
  • The Medical Council of New Zealand advises that the doctor speak with the patient about the presence of a third person in private, away from the nominated third person. 
  • If a doctor requires a third person to attend a consultation they should preferably be another health professional. 
  • Third persons should be made aware of the confidential nature of the consultation.

References

  1. Right 8, Right to Support, The Code of Health and Disability Services Consumers’ Rights
  2. Medical Council of New Zealand, Sexual Boundaries in the Doctor–Patient Relationship (2009)
  3. The Health and Disability Commissioner, report on opinion – case96dc2761, September 1997
  4. New Zealand Society of Physiotherapists, Guidelines on Support Persons and Chaperones (2004)
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