In brief
- Consider using a chaperone for some or all physical examinations, regardless of the gender of the patient or the long-term nature of the doctor-patient relationship.
- Obtain express consent when the chaperone’s only role is that of an observer.
- Document a chaperone’s presence and the patient’s consent in the medical record.
- Consider additional risk management strategies when performing physical examinations, including being particularly respectful of patient privacy, maintaining appropriate boundaries, and demonstrating professional behaviour at all times.
In recent years, Colleges and legislatures have reinforced policies of zero tolerance for sexual abuse, redefined what constitutes sexual abuse, and increased penalties around sexual abuse.
In light of the significant consequences of an allegation of sexual abuse, physicians may ask what they can do to ensure boundaries are respected and patients feel safe.
One solution is to have a chaperone present for some or all physical examinations, irrespective of your gender or the patient’s, or the fact that you and the patient have a long-standing professional relationship. Even if you previously decided to not have a chaperone present for some or all of your patient examinations, now might be a time to reassess your approach, particularly with examinations of a sensitive nature.
Deciding whether to use a chaperone
A chaperone can offer protection and reassurance to you and your patients. Patients may feel less vulnerable and more comfortable with a chaperone present during a sensitive physical examination. At the same time, a chaperone may reduce College complaints or legal actions.
When deciding whether a chaperone is appropriate, you will want to consider the expectations of your College. Some Colleges recommend that physicians have a chaperone, or at least offer to have one, for sensitive examinations such as pelvic (rectal, vaginal, testicular) or breast exams. Some Colleges also encourage physicians to strongly consider a chaperone for contentious examinations, such as independent medical examinations.
If you are practising in a healthcare institution such as a hospital, speak with the administration about policies or procedures around the use of chaperones in the institution. Other factors you will want to consider when deciding on a chaperone include such things as the type of examination, your relationship with the patient, and the patient’s disposition.
Patient consent is always necessary for a chaperone to be present. When a member of the clinical team is both assisting with the examination and acting as a chaperone (e.g. a nurse), consent may be implied. However, a patient’s express consent is required if the chaperone’s only role is as an observer.
The patient’s consent and the chaperone’s presence should be documented in the medical record. If the patient does not consent to a chaperone, you should also document this in the medical record.
Patients who are initially reluctant to have a chaperone may change their mind if you clearly explain the chaperone’s role. For example, you may tell patients the chaperone is strictly an observer who is there to protect them and ensure they feel safe. Patients should be assured that the chaperone will respect their privacy and confidentiality.
If you feel a chaperone is necessary despite the patient's contrary wishes, you might consider as a last resort deferring a non-urgent examination and referring the patient to another physician who is prepared to perform the examination without a chaperone. You should pay particular attention to ensuring the patient understands the clinical consequences of delaying care.
A referral should not delay required or urgent treatment. If the patient does not consent to a chaperone and you decide to delay care or not provide care, the patient might complain to the College or human rights tribunal.
If the physical examination is necessary to address an urgent or emergent condition and the patient does not consent to a chaperone being present, it is generally advisable to proceed with the urgent examination taking into account the additional risk management steps discussed below.
Selecting a chaperone
Preferably, the chaperone should be a trained health professional familiar with the examination so that, if necessary, they can confirm the examination was appropriately conducted. A trained chaperone may also feel more comfortable raising questions or concerns about how the examination is conducted.
When a trained health professional is not available, non-medical staff—such as an office assistant—may substitute. However, these individuals may not have the clinical knowledge necessary to comment on the appropriateness of the examination. Some Colleges offer training courses for office staff to help them understand their roles and responsibilities as chaperones. If you are considering using non-medical staff as chaperones, you will want to investigate any chaperone-training resources available through your College or medical professional association. Regardless of who is chaperoning, it is your responsibility to discuss their role with them, especially the need to respect patient dignity and privacy.
In some cases, it may be reasonable to suggest that a patient bring a person of their choosing to the examination, particularly when you do not have the resources to offer a chaperone.
Alternatively, some patients may wish to have a family member or friend present during the examination, in addition to any chaperone you offer. You should generally comply with any reasonable request. Consider, however, that not all friends or family members will be impartial and might not fully understand the purpose or steps of the examination.
Respecting boundaries
If patients do not have enough information about what an examination will entail or if they misunderstand the purpose of an examination, they may feel boundaries were not respected. These individuals may be more likely to file a College complaint or start a civil action. There are other risk management strategies you can consider to maintain appropriate boundaries in addition to having a chaperone.
Respect patient privacy
Always provide a private space for patients to dress and undress (e.g., by the leaving the room, offering the patient a separate room to change in, or having a curtain between the you and patient). This applies to you, your staff, and the chaperone. Provide a suitable cover or gown. Avoid removing or adjusting patients’ clothing during the examination without express consent.
Communicate clearly and seek consent
Before you begin, ensure the patient has consented to the examination. Explain what body parts will be examined and why. Alert the patient before approaching a sensitive area. For example, patients may not know if the procedure will involve palpation. If an examination involves palpation, inform the patient in advance.
If you need to modify the examination while it is underway, tell the patient and reconfirm consent.
Encourage the patient to ask questions and to speak up immediately if they feel uncomfortable or are in distress. After the examination is complete and the patient is given an opportunity to get dressed in private, it can be helpful to ask the patient if they have any questions or concerns.
Remain professional
Some physicians try to alleviate patients’ anxiety during sensitive examinations by using humour, making lighthearted comments, sharing personal stories, or minimizing the significance of the examination. While it’s natural to try to put patients at ease, these types of comments should be avoided in circumstances involving sensitive examinations as they might be misinterpreted by the patient.
In the CMPA’s experience, the best way to minimize patient discomfort is to be personable and compassionate, and to ensure that your professional behaviour is beyond reproach.
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