The MIPS clinico-legal adviser’s line quite often receives calls regarding intimate examinations that have gone wrong.
At a minimum, the result is the breakdown of the patient-doctor relationship. At worst the consequences are much more serious and can result in criminal accusations, the involvement of local law enforcement and immediate action by AHPRA (in order to protect the public) who frequently place conditions on a practitioners practice.
Whilst the vast majority of cases that are notified to MIPS could be averted through improved communication, like any medical interaction; intimate examinations are a learned skill that need to be practised and developed.
Fortunately, many Australian medical schools recognise the need to formally teach intimate examinations to medical students and sensitive and ethical teaching has replaced the historical technique of learning by examining anaesthetised patients. In MIPS’ experience, it is often the more experienced healthcare practitioner that requires reminding on how to handle these examinations.
Priorities when performing an intimate exam are:
Consider is it appropriate for the patient’s care? Intimate penetrative vaginal examinations on females who have not been sexually active should be avoided unless there are exceptional circumstances. MIPS is aware of a recent incident where for religious and cultural reasons a patient had not consented to the vaginal examination which formed a normal part of a gynaecological laparoscopic procedure to investigate pelvic pain. Both patient and gynaecologist ended up traumatised by the accidental alleged assault. Other intimate examinations that were previously commonplace may now be considered by peers to be of debatable value. For example, a routine breast check in an antenatal patient.
Explain why the intimate examination is necessary and document. Many patients have no understanding of the medical system. A patient with rectal bleeding recently complained regarding a perceived unnecessary rectal examination performed by a practitioner who had already recommended urgent transfer to the Emergency Department.
Obtain consent. Explaining examinations is vital however the patient also needs to actively consent and can of course withdraw consent at any time. Standard normal phrases that you use in almost every intimate examination such as “You are in charge - if at any time you want me to stop the examination just say so” are helpful. They create good habits and are ‘dynamite’ in a legal defence.
Display appropriate manners and be respectful of the patient. Patients (unless very infirm or unwell) must be allowed privacy to undress and should be given the appropriate instructions and equipment to protect their modesty with sheets/garments. The gaping theatre garments held together by strings at the back appear here to stay but decorum can still be protected and should be paramount.
Offer a chaperone and provide one if there is ANY concern by either you or the patient. Chaperones can be expensive and time consuming, but so is an AHPRA complaint. Whilst many practitioners do not use a chaperone it is vital to do so if your employer requires it or you or the patient wish to have someone present.
Gloves are very powerful protection. Certainly MIPS’ experience is that not wearing gloves, when that is best practice, can be hard to defend. Current undergraduate teaching is to wear gloves for all examinations other than breast examinations. Some clinicians still do not do so for scrotal examinations arguing that it affects the accuracy of the examination. If you wish to continue gloveless then make sure you can find a peer who agrees with your decision – we will need him/her if there is a complaint!
Document your examination. MIPS recently had to assist a GP who allegedly performed an inappropriate breast examination but did not record a breast examination at all in his notes. Whilst the examination may have been entirely appropriate its omission from the notes alerted ‘mild suspicion’ at a minimum.
Finally, if you feel that an intimate examination went badly and was misinterpreted, please call MIPS’ 24hr Clinico-Legal Support on 1800 061 113 and let us know immediately, we are here to guide you through and offer you advice.