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As the burly 60-year-old man lumbered on to the couch, my eye caught the laminated notice on the wall.
‘Would you like a chaperone?’ I asked.
He looked startled. ‘I’m a big lad, love!’
‘I think we’ll be alright with each other,’ I agreed.
We laughed nervously.
I regretted the introduction of bizarre, slightly distasteful innuendo into a relaxed consultation.
Before the GMC and Care Quality Commission issued guidance, I had never considered I needed a chaperone. When a trainee informed a middle-aged man that she wasn’t prepared to examine him alone, I was surprised.
Apparently, a witness was not only supposed to prevent doctors mistreating patients, but also deter them from molesting us. A mundane aspect of my job had become fraught with the possibility of actual, or falsely alleged, sexual assault.
By the time I’ve defined the quaint word, outlined to the erstwhile trusting patient the hazards of being examined by me, and recorded everything and got consent, there is barely time to give the genitalia the thorough drubbing required.
There are sporadic, depressing instances when medics abuse the trust implicit in the doctor- patient relationship. Mostly their motives are bleak and manipulative. But sometimes, they are just inexcusably crass.
Long ago we were taught, ‘if you don’t put your finger in it, you’ll put your foot in it’. A conscientious doctor was expected to perform rectal examinations ‘just in case’ at every clerking.
Only patients fortunate enough to have had a recent myocardial infarction, in whom rectal stimulation was purported to risk arrhythmia and sudden death, were excused.
I recall one student who decided he lacked experience of the art. Without informing anyone, he spent an afternoon drawing the curtains around each bed in succession on the ward, and slipping behind to perform a rectal examination on every patient. Nobody remonstrated, and the tea trolley rattled along behind.
As doctors we invade our patients’ personal space many times a day. It is easy to become blasé, and forget the flux of power and vulnerability. I remember the first patient I ever touched: a frail, jaundiced man during a ward round.
Encased in my oversized starched white coat, which somehow absolved us from the strange intimacy, I tentatively kneaded his knobbly liver edge. Although he smiled encouragingly,
I struggled to overcome an instinctive reluctance and my fear of hurting him.
These days, I must make a conscious effort not to grab my patients, tug at their clothes and position their body parts for my convenience. Just as a plumber cannot do his job without enthusiastic deployment of the plunger, we cannot do ours without touch. We can diagnose the wince of the fibromyalgia patient and the inch of the trauma victim. We reach out to establish rapport.
Yet I feel constrained to hug the bereft with the warmth that once felt natural. Instead, I suffice with a pat on the hand, and push the tissue box across the desk. As a small, increasingly raddled female GP, I know I am less likely to be accused of assault than differently endowed doctors.
Still, I deplore the insidious effects of another example of over-regulation, which encourages patients to be wary of their doctors, and us to be terrified of them.
Jo Cannon is a GP in Derbyshire
This resonates! My laminated chaperone poster is on the back of my door, usually hidden by my coat, I cant remember asking if somebody wanted a chaperone, even since CQC ,and sometimes I feel vaguely like I'm breaking the rules but most of the time it would certainly create more issues than it purports to prevent. And would I really want to carry on being a GP if I couldnt give those few patients that need it a hug or allow the older gentleman who politely checks with me if it is OK to give me a small kiss on the cheek in recognition of an appointment that gives him the will and confidence to keep going?
At last, it is great to see some common sense being applied to the subject of chaperones. I don't often explicitly offer a chaperone, but do make sure the chaperone poster is prominently visible, and ensure that I am sensitive to the needs of those who might need one. I believe there are two essential elements to ensuring a safe examination free from the risk of accusations of inappropriate behaviour. Firstly of course is consent, I always verbally check that the patient is happy and comfortable for the examination to proceed. Secondly is giving the patient control, for intimate examinations I will always tell patients that if they want me to stop for ANY reason then they must do so. I am often surprised how readily some patients agree to be examined, but also sometimes at the reluctance of others to expose even a small area of skin. It is essential even when taking a blood pressure or examining an arthritic wrist to ask the question "do you mind if I just..."
I do agree with the comment regarding "the insidious effects of another example of over-regulation, which encourages patients to be wary of their doctors, and us to be terrified of them". There is something very upsetting to see the horror on the face of a mother as she says "you can't do that, he's a doctor" to their Down's syndrome child who spontaneously gives me a hug at the end of their consultation.
I also think we need to remember the possibility of unintended consequences, leading to potential harm caused by the whole chaperone offer/discussion. As described, the raising of the chaperone issue, brings up the possibility of the consulting-room, being thought of as a potential place of abuse. For those patients who have been abused, this thought can cloud the doctor-patient relationship, and shake the idea of a safe neutral space, at their GP's- the person who may be the only person they have discussed their past with.
But the experiences of male and female doctors here can also be very different, although it is pretended by CQC/GMC etc that it's the same. The chaperone really is to protect the doctor, and the male doctor is more at risk of allegations, and perhaps the consequences of "crass" behaviour. I agree that consent is everything- even fundoscopy needs an explanation- it's all about personal space and safeguarding dignity and respect.
I too trained at a time when female students and doctors were not advised that they needed to offer a chaperone . Now I usually remember and patients look at me with surprise when I offer as a middle aged woman . To me it feels as if I am suggesting that there may be something inappropriate in what I am about to do!
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I have never once had a patient accept the offer of a chaperone- most greet the suggestion with horror!
It has been a huge societal shift during the 25 years of my working life and there is complete bafflement between myself and those of my junior colleagues in training who would never do an intimate examination without a chaperone - put there for their own protection.
If we get to a point where the zeitgeist is that we simply can’t trust patients to not falsely accuse us of molestation, and work on the basis that they will, I am afraid I shall happily leave. That is not the type of medicine I can practice.
For now I will accept the giant hug offered to me by a 5 year old, the kiss on the cheek from an old lady, and the hand shake that moved through a double hand clasp to an embrace from a grateful young man. All of which happened yesterday.
We cannot do this job without touch.
Very well written.
I stopped while riding my push bike to check a schoolgirl was ok - she was on her way to school and had had to stop biking in order to use her inhaler. Her classmate was further up the road waiting for her. I am a female, middle aged GP and a mother. I felt a awkward as I had my stethoscope in my bag but did not want to examine her let alone touch her for the very reasons you are describing. While I was busy doing the right thing talking with her, calling over her classmate and asking her if I could ring her mum for her my moral dilemma was solved: another middle-aged mother stopped her car and came over to help: she put her arm around the girl and spoke reassuringly to her. That really did the trick and after the girl had spoken to her mum on her mobile, she rode off to school. What a shame when doing the right thing is no longer the same as doing the best thing...