The dilemma: I have to undertake an intimate examination unexpectedly during a home visit, and the patient lives alone. I don’t want to delay the examination, but I want to ensure the appropriate steps are taken. How should I proceed in this situation?
Dr Gabrielle Pendlebury, medicolegal adviser at Medical Protection advises:
This dilemma is something that every GP will no doubt encounter at some point in their career. The desire to be efficient and relieve anxieties around suspected pathology, for both the patient and the clinician, can sometimes lead to practise that neglects issues around autonomy, communication and consent. This can inadvertently lead to complaints or allegations of inappropriate actions.
A good starting point is always the GMC’s Good Medical Practice which indicates that 'if you assess, diagnose or treat patients, you must adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient'.
The guidance also emphasises that you should treat 'patients as individuals and respect their dignity and privacy'.
Is the examination required?
Firstly, the examination must be clinically justified and you must be prepared to give the clinical rationale for the examination and why it was required at that time without a chaperone. Medical Protection’s experience is that it is rare for a doctor to be accused of assault if a chaperone is present. Chaperones provide protection for doctors and patients.
When undertaking an intimate examination, it should be a norm to always offer the patient a chaperone. But in this instance where the patient lives alone and no chaperone is available, it is important to step back and consider whether or not the examination is urgent on a clinical basis.
If the examination is not urgent, then it might be possible to simply rearrange the appointment for a time when a chaperone will be available.
If the examination is urgent on a clinical basis and the doctor has enough information from the patient’s history that indicates the patient would require a hospital admission in any event, then it may be appropriate to admit them to the hospital without an examination.
If the examination is urgent and a hospital admission is not indicated based on the patient’s history, there may be occasions when a doctor may go ahead with the examination in the absence of a chaperone.
Conducting the examination
The intended examination should be explained carefully to the patient and the patient’s consent should be obtained and recorded. Also, the fact that the patient was examined in the absence of a chaperone should be recorded, together with the rationale. The medical records need to be especially clear regarding the urgency of the examination if there are cultural or language issues at play.
The GMC guidance Intimate Examinations and Chaperones states: 'Intimate examinations can be embarrassing or distressing for patients and whenever you examine a patient you should be sensitive to what they may think of as intimate. This is likely to include examinations of breasts, genitalia and rectum, but could also include any examination where it is necessary to touch or even be close to the patient.'
It is important to consider what the patient would consider to be an intimate examination. Allegations of assault have arisen in relation to the placing of ECG leads, fundoscopy or inadvertent touching of the patient in pursuance of a legitimate clinical examination. Therefore, clear and comprehensive communication of the nature of the examination is essential to prevent the possibility of misunderstanding but also to allow the patient to decline the examination.
Further guidance is therefore offered by the GMC: 'Before conducting an intimate examination, you should:
- explain to the patient why an examination is necessary and give the patient an opportunity to ask questions
- explain what the examination will involve, in a way the patient can understand, so that the patient has a clear idea of what to expect, including any pain or discomfort
- get the patient’s permission before the examination and record that the patient has given it
- give the patient privacy to undress and dress, and keep them covered as much as possible to maintain their dignity; do not help the patient to remove clothing unless they have asked you to, or you have checked with them that they want you to help.'
It may become apparent during the course of an examination that a chaperone is required, for example, if a patient examination reveals the necessity for a rectal examination when this was not discussed or consented. Before continuing with the rectal examination, there should be a discussion regarding the proposed examination and its urgency. This may even need to be considered if the patient becomes uncomfortable with the usual clinical examination of body systems.
In Medical Protection’s experience, these situations can arise when least expected but you can always contact your medical defence organisation for further advice if the solution is not immediately clear.