In Canada, the past few years have seen more attention focused on reports of sexual misconduct and abuse.1 In this environment of heightened focus, some authorities and organizations are changing their policies around the issue. For example, medical regulatory authorities (Colleges) and legislatures are enacting or reinforcing policies of zero tolerance for sexual abuse,2 including redefining what constitutes sexual abuse, and increasing transparency and penalties for sexual abuse.3
This may be an appropriate time for physicians to ask: what can I do in my practice 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 longstanding professional relationship. Even if you have previously decided you don’t need a chaperone with some or all of your patient examinations, now might be an appropriate time to reassess your approach, particularly with examinations of a sensitive nature.
When deciding whether using a chaperone might be prudent, you may want to consider the following.
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, you might find that a chaperone can reduce College complaints or legal actions.
When deciding whether a chaperone is appropriate, you should consider several factors. 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.4 Some Colleges also encourage physicians to strongly consider a chaperone for contentious examinations, such as independent medical examinations.5
If you are practising in a hospital, speak with the hospital administration about policies or procedures around the use of chaperones in the hospital. 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. For example, some patients might not want a third party present during an examination.
Patient consent is 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. The additional risk management steps discussed in the “Respecting boundaries” section of this article should be considered in these circumstances.
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.6 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 with them their role and your expectations, especially the need to respect patient dignity and privacy.
In some cases, it may be reasonable to suggest the 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 respect patient privacy by leaving the room when patients undress and redress. 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 ensure that your professional behaviour is beyond reproach.
The bottom line
- Re-evaluate whether to use 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. Chaperones can offer protection and comfort for you and your patients, particularly during sensitive physical examinations.
- While consent may be implied when a member of the clinical team (e.g. a nurse) is both assisting with the examination and acting as a chaperone, 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.
- Irrespective of whether a chaperone is used, consider employing other general risk management strategies when performing physical examinations, including being particularly respectful of patient privacy, maintaining appropriate boundaries, and demonstrating professional behaviour at all times.
References
- Rotenberg C. Cotter A. Police-reported sexual assaults in Canada before and after #MeToo, 2016 and 2017. Ottawa (CA):Statistics Canada; 2018 Nov 8, Catalogue no. 85-002-X
- College of Physicians and Surgeons of Alberta [Internet]. Edmonton: CPSA; 2018 June 11. Creating Safe Spaces for All in Alberta’s Healthcare System [cited 2019 Jan 10]. Available from: http://www.cpsa.ca/creating-safe-spaces-for-all-in-albertas-healthcare-system/.
- For example, see Ontario’s Protecting Patients Act, SO 2017, c 11, Québec’s An Act to amend various legislation mainly with respect to admission to professions and the governance of the professional system, SQ 2017, c 11 and Alberta’s Act to Protect Patients, SA 2018 c 15
- For example, see the following: College of Physicians and Surgeons of British Columbia document, FAQ on Boundary Violations in the Patient-Physician Relationship, November 2017; College of Physicians and Surgeons of Alberta document, Chaperone Requirements, June 2014; College of Physicians and Surgeons of Newfoundland and Labrador document, Practice Guideline on Chaperones & Sensitive Examinations (December 2016).
- For example, see the College of Physicians and Surgeons of British Columbia’s document, Guideline on Independent Medical Examinations, revised February 2013.
- For example, the College of Physicians and Surgeons of Alberta offers a Chaperone Training Workshop.
