• The first thing to remember is that whilst doctors and nurses examine patients several times a day, being examined is a relatively infrequent experience for a patient and can unsurprisingly lead to anxiety and apprehension.
• Therefore, when examining a patient, please give attention to the environment ensuring adequate privacy is afforded in order to maintain the patient’s dignity.  This is BOTH the health care professional’s and chaperone’s responsibility.  For example, after they have undressed, make sure they are not kept waiting too long before the examination or procedure.  Also, make sure their dignity is maintained by covering up exposed areas until the examination or procedure is due (use the large paper rolls or the patient’s own clothing or even both).   Make sure the curtain is drawn around them and the window blinds are drawn closed.
• The chaperone must be INSIDE the curtain otherwise they cannot observe what is being done.  DO NOT STAND OUTSIDE THE CURTAIN.   Where the chaperone postiions themself within the curtain space depends on what is being examined.  They need to be able to see what is being done.   If the chaperone is unsure where to stand, ask the health professional to advise them.
• The chaperones role is as an impartial observer.   Also attend to the patient’s comfort.
• Refrain from personal comments like ‘you smell nice’.  This is a clinical procedure.
• The chaperone leaves the room ONLY when the patient is dressed and ready to resume the consultation.

Some Key Things to Remember:

• For most patients respect, explanation, consent and privacy take precedence over the need for a chaperone. The presence of a third party does not negate the need for adequate explanation and courtesy and cannot provide full assurance that the procedure or examination is conducted appropriately. Adequate information and explanation as to why the examination or procedure is required should be provided and where necessary, easily understood literature and diagrams can support this verbal information. For example, as doctors it makes sense to do a rectal examination in a male patient complaining of prostatic urinary symptoms. However, a patient may not understand why a doctor needs to put a finger up their bottom for something that they are complaining of from their front end.
• In a similar vein, it is unwise to assume that the patient understands why certain examinations are being conducted or why they are done in a certain manner. For example, patients need to be told why both breasts are examined when they may complain of a lump in only one, or why a vaginal examination maybe necessary if a women complains of abdominal pain or why the testes may be examined in a child with abdominal pain. There was a case where a female patient complained against her male doctor for conducting an inappropriate breast examination. She complained that she was asked to strip off and display her naked torso and that the doctor spent some time looking at her breasts. He then asked her to raise her arms and examined the ‘normal’ breast. The case was dismissed from the GMC but illustrates how a simple explanation of what the examination entails could prevent problems.
• Most patients would value a chaperone… a study looking at attitudes of patients towards the use of chaperones carried out in Tyneside found that 90% of female patients and 78% of male patients thought that a chaperone should be offered for ‘intimate’ examinations. However, most patients decline the offer of a chaperone for a number of reasons: because they trust the clinician, think it unnecessary, require privacy, or are too embarrassed.
• Complaints involving allegations of improper examination by a doctor are very rare. Where allegations of indecent assault during a clinical examination do occur almost all are against a male doctor and a small but significant minority of cases involve a male doctor and a male patient.
• In all cases where the presence of a chaperone may intrude in a confiding clinician-patient relationship their presence should be confined to the physical examination. One-to-one communication should take place after the examination, once the chaperone has left.
• The use of the feminine gender equally implies the male and similarly the use of the male gender equally implies the female.
• The offer of a chaperone and their presence should be recorded in medical note.

• Establish there is a genuine need for an intimate examination and discuss this with the patient. Explain to the patient why an examination is necessary and give the patient an opportunity to ask questions.
• Offer a chaperone or invite the patient to have a family member/friend present. If the patient does not want a chaperone, record that the offer was made and declined in the patients notes.
• Obtain the patient’s consent before the examination and be prepared to discontinue the examination at any stage at the patient’s request. Record that permission has been obtained in the patients notes.
• Once the chaperone has entered the room give the patient privacy to undress and dress. Use drapes where possible to maintain dignity. Facilities should be available for patients to undress in a private, undisturbed area. Intimate examination should take place in a closed room or well-screened bay that cannot be entered while the examination is in progress. Examination should not be interrupted by phone calls or messages. If you plan to lock your door, please ask the patient first if it is okay. Some patients (especially those with a history of sexual abuse) may find the click of a door being locked very distressing. So – seek permission and ask ‘is it okay if i lock the door so that your privacy is maintained?’.
• There should be no undue delay prior to examination once the patient has removed any clothing – a delay just increases a patient’s anxiety and can be undignifying.
• During the intimate examination
  
  • Offer reassurance and be courteous
  • Explain what you are doing at each stage of the examination.
  • Keep discussions relevant and avoid unnecessary personal comments like ‘you smell nice’, ‘that’s a very nice skirt’, ‘very cute piercing/tattoo’
  • Encourage questions and discussion
  • Remain alert to verbal and non-verbal indications of distress from the patient Any requests that the examination be discontinued should be respected.
• At the end of the examination and once the patient is dressed the findings must be communicated to the patient – explain what you found, and what you propose to do next. If appropriate this can be used as an educational opportunity for the patient. The professional must consider (asking the patient as necessary) if it is appropriate for the chaperone to remain at this stage.
• If a chaperone has been present record that fact and the identity of the chaperone in the patients notes.
• Record any other relevant issues or concerns immediately following the consultation.

NB Where appropriate a choice of position for the examination should be offered for example left lateral, dorsal, recumbent and semi-recumbent positions for speculum and bimanual examinations. This may reduce the sense of vulnerability and powerlessness complained of by some patients.

Explanation is the key to ensuring patients understand what is being asked of them or done to them.  In this way, it gives them truly informed choice.    Explanation is therefore also the key to minimising complaints.   Remember, patients are not doctors or nurses and so cannot second guess why you might be doing something.  For sure, there are some things that you will do that will be obvious to them as to why you are doing them (like listening to the heart for chest pain).   But there are other things that might appear illogical to them and some of these are listed below.   You should explain more explicitly in these situations and ensure the patient understands.

• Intimate examinations cause anxiety for both male and female patients.
• A male patient might be puzzled as to why you are checking their back passage (i.e. a PR) when they came in with front passage (urinary) complaints.
• A female patient might be wondering why your hand is holding up her breast even though you know you are feeling for the apex beat.
• Some patients may feel uncomfortable at how close you will get to them when examining the eye with an ophthalmoscope – tell them beforehand.
• A patient may wonder why you are feeling their groin (inguinal area)
  • in an abdominal examination(even though you know you are checking for hernia)
  • when all they came in for was pain in the calf and cold legs (even though you are checking the peripheral vascular system)
  • when all they complained of was sore neck and axillary lymph nodes (even though you know you are checking for inguinal lymph nodes)

Try not to examine the genitalia of men by asking them to stand and drop their trousers. It is embarassing and undignifying for them. Perform the examination on the examination couch. This will help the examination ‘feel’ clinical, help them feel more dignified and reassure them that you are taking their matter seriously.

During an intimate internal examination it is strongly recommended that surgical gloves be worn. The glove acts as a physical barrier, keeping the examination on a clinical basis, limiting the possibility of sexual connotations. Situations where a healthcare professional may reasonably not wear gloves would be in a life-saving situation where gloves are not available. Healthcare professionals should always seek to carry gloves when on call.