Practice dilemma - Patient refuses a chaperone

The Dilemma Miss Thompson is a 21-year-old student who has come to your practice rather than her university doctor as it is the holidays.[QQ]You have never met her before and have no medical history records. She states she is normally well except for a breast lump she has had for two months. She does not take any regular medicines and is normally fit and well. She attends your clinic for a cough, which she has had for two days. Once the cough has been dealt with, she mentions she would like the breast lump examined. A previous doctor checked it out and said there was nothing to worry about but she was still concerned. You offer a nurse chaperone, which she declines stating that you are a doctor and she is not worried about that, she just wants her lump checked out. What should you do?

Time should be spent explaining and reassuring (Photograph: SPL)
Time should be spent explaining and reassuring (Photograph: SPL)

A GP's view: Dr Barney Tinsley is a GP partner in Harrogate
The set of clinical circumstances suggests the patient is much more worried about the breast lump than the cough she initially presented with - not an uncommon situation for GPs.

In this instance, as well as maintaining a friendly manner, I would insist on having a female chaperone to oversee the propriety and the maintenance of patient dignity during the breast examination, as per GMC recommendations.

The patient should be given privacy while disrobing, and when dressing after the examination, with the female chaperone offering any extra assistance, should it be needed.

Prior to an examination, I would take the clinical history of the appearance of the breast lump. Although lumps, such as benign fibroadenomas, are relatively common in young women, it would be very easy to be dismissive of it, which may not give the patient the reassurance she seeks.

Thus, after a full history and careful, chaperoned examination, it may be appropriate to refer her to the local breast clinic.

Time should be spent ex-plaining and reassuring. The patient should be given a printed copy of the consultation summary for her usual GP.

Giving her a copy of an appro-priate referral letter to the breast clinic may also be useful.

Should a chaperone be unavailable, I would try to make an appointment with another GP, preferably female, as soon as possible.

A medico-legal opinion: Dr Sonya McCullough is a medico-legal adviser for the Medical Protection Society
Intimate examinations include breasts, genitalia and the rectum. They extend to an examination where it is necessary to touch or be close to the patient.

You do not see this patient regularly and it would be wise to have a chaperone present for your own protection and for her reassurance.

You offer a nurse chaperone which is appropriate - practices should no longer use untrained practice staff to fulfil the role of a chaperone. Chaperones need to understand what a legitimate intimate examination entails or when it is not appropriate.

It is important to explore the reasons why the patient does not want a chaperone and to address any concerns she may have. If she still declines you will have to decide if you are happy to continue based on clinical need and the requirement for protection against potential allegations of improper conduct.

You may wish to explain that you would prefer to have a chaperone present. If this offer is still declined and you are concerned, you do not have to undertake an examination.

However, ensure arrangements are made for her to be seen by a female member of staff. Record the offer and declining of a chaperone in the notes. If a chaperone is present, record that fact and note their identity.

You may find the GMC guidance, 'Maintaining Boundaries' useful.

A patient's view: Antony Chuter is an expert patient
The GP needs to examine the breast lump and may wish to have a chaperone present. As a patient, if I have a problem and have not been reassured by a previous consultation then I too would ask for a second opinion.

A consultation is a partnership between patient and GP and the balance of power needs to be equal.

I would hope that the GP would explain that the chaperone is for both patient and GP and that it is normal to have one present when conducting an intimate examination.

The difficulty could come if the patient refuses to be examined with a chaperone present.

If the GP feels uncomfortable about performing the examination without a chaperone then the examination should not go ahead. This may not be considered a satisfactory outcome for either side, however. It would be far better if the GP could reassure the patient about the presence of a chaperone.

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