Observers: chaperone, protect and reassure

Quick guide

• During some patient examinations, observers may be helpful to reassure the patient and to protect the doctor.
• Before examining a patient, always explain the nature of the examination and the reason for performing it and obtain consent.
• It is important to document all offers for an observer to be present and the patient’s response. If an observer is present, record their name and title in the medical record.

Why use an observer?

The presence of an observer (previously called a chaperone*) as a witness to a medical examination may benefit both you and the patient. It can be reassuring to a patient who is fearful, vulnerable or embarrassed.

Regardless of your intentions, if a patient perceives that your remarks are inappropriate or that your examination was insensitive or improper, they may complain. The presence of an observer may also provide some protection for you in such a situation.

*Note: The term chaperone was also used to refer to the situation whereby a doctor has a continuing condition on their registration that requires them to be monitored in compliance with Ahpra conditions. The scope of this aspect of the chaperone role has changed and may now also be referred to as a ‘practice monitor’.

When to use an observer

The Medical Board of Australia’s Guidelines: Sexual boundaries in the doctor-patient relationship do not specify when an offer of an observer should (or must) be made. The AMA’s position statement identifies circumstances where a medical practitioner may wish to have an observer present including:

• when one is requested by the patient, during an intimate examination
• if a patient appears particularly uncomfortable/reluctant/ distressed
• or where the doctor is uncomfortable.

Be aware, as the guidelines highlight, that what a patient considers to be an intimate examination may be affected by their cultural values and beliefs, so it is important to be alert to signs of a patient’s discomfort or reluctance.

Exercise your professional judgement to determine when the offer of an observer is appropriate. Many patients may not want a third person present during their examination and will decline the offer. If the patient does decline your offer, discuss the patient’s reason and you may then be comfortable proceeding with the examination without an observer. Or, you may still have concerns and consider that an observer is needed. If so, you are able to decline to conduct the examination, if it is not urgent, and consider referring the patient to a colleague or other further steps depending on the clinical situation.

The practice of medicine depends on trust and confidence between doctor and patient and appropriate physical examinations are a vital part of the doctor-patient relationship. Once trust and confidence have been established, you may consider the routine offer of an observer is not necessary.

Circumstances requiring caution

Practically, it is likely that an appropriate adult will always be present when examining children. For young people, depending on the circumstances, you may wish to suggest having an observer present to help the patient feel at ease. In other circumstances, this may lead them to feel more uncomfortable or embarrassed and there may be a risk of them disengaging with care.

Particular care should be taken when:

• conducting an intimate examination on any patient, regardless of how long they have been your patient
• there are any communication difficulties or language barriers, for example the patient is from a non-English speaking background
• a woman attends for the first time with a problem requiring breast, anal or genital examination
• a patient consults with you after hours and you are alone in the practice
• the patient is a child or young person or there is an impairment which suggests they may not be able to consent to the examination
• a patient uses sexually explicit language, displays inappropriate feelings or exhibits sexualised behaviour
• the patient has a history of sexual assault
• conducting a medico-legal assessment (such as acting as an independent assessor for a WorkCover claim or similar) on a person who is not a patient of the practice.

Medico-legal assessments have a unique set of challenges as the patient can feel the doctor is adversarial. We would recommend a low threshold for the presence of an observer in these situations.

Observer or support person?

An observer should be qualified (a nurse – RN or EN, or other registered health practitioner) or someone appropriately trained (other clinical support staff) so that they fully understand the role that they are performing on behalf of the patient. Usually, the examining doctor will initiate the offer of an observer. The observer should be a person acceptable to the patient. In most cases, they will be a person of the same gender as the patient.

A patient may also request the presence of a support person, usually a patient’s friend or relative. The presence of a support person may be the most appropriate approach in some situations (for example if the patient is a child or young person, or if there are cultural reasons for their presence). When using a support person, take care to maintain the patient’s privacy and dignity and ensure the patient willingly consents to their presence.

The role of a support person is not equivalent to that of an observer so there may occasionally be times when both an observer and a support person are present.

What if an observer is not available?

If a patient requests an observer and a suitable person is not available, you may wish to offer to reschedule the appointment so that the observer can be arranged. Or, you may refer the patient to a colleague if they would feel more comfortable with another doctor (for example, one who is the same gender as the patient or a different gender to you). If the consultation is deferred, you should counsel the patient about any effect the delay may have on their health.

Other third parties

You must obtain consent from your patient for any other person to be present in the consultation. This could include, for example, interpreters, a registrar, medical or nursing student or somebody undertaking a review of your practice. This must be done prior to the consultation, such as in the reception area or waiting room. It is not acceptable to ask the patient in the consulting room, or in front of the third party as the patient may feel obliged or pressured to agree.

Documentation

It is important to document in the patient’s medical record that an observer has been offered and whether the patient accepted or refused. It can be easy to overlook the need to record where an offer was declined, but this is an important part of the discussion.

If a patient agrees to have an observer present, or a support person or another third-party is present at the patient’s request, ensure you record this in the clinical records. Document who is present including their name and job title, and/or relationship to the patient.

Additional resources

Avant factsheet: Boundary issues

AMA position statement “Maintaining Clear Sexual Boundaries Between Doctors and Patients and the Conduct of Patient Examinations 2019”

Medical Board of Australia - Sexual boundaries in the doctor-patient relationship

RACGP standards 5th edition criteria C2.2

Ahpra Chaperone Protocol

You can find additional resources including articles, podcasts and webinars in Avant Resources, under the Practising professionally topic.