The Attitudes and Practices of General Practitioners about the Use of Chaperones in Melbourne, Australia

Introduction. To consider the use of medical chaperones during certain clinical examinations is important whether one practises as a specialist, nurse, medical student, or generalist. Chaperones have been used by doctors conducting intimate examinations for many years but their true extent remains largely unknown. Until recently, there was no national guidance in Australia. Aim. To explore the attitudes and practices of general practitioners (GP) regarding their use of chaperones in urban Melbourne, Australia. Method. Qualitative two focus groups involving seventeen GPs from two locations. Discussions were audio-taped, transcribed verbatim and analysed. Results. Common themes and subthemes emerged which were grouped into three main areas: (a) practitioner-related, (b) patient-related and (c) practice related. Discussion. This is the first study from an Australian primary care perspective to gauge the attitudes and experiences of GPs on their use of chaperones. It will provide vital information to inform the next step of extending this research to a national GP audience. From an international perspective, this study provides an excellent template for other primary care clinicians to conduct research in this important field of doctor-patient relationship.


Introduction
Medical chaperones are people, often health professionals that act as third-party observers during certain clinical examinations (most often intimate examinations), either at the request of the patient or because of the doctor's clinical judgement. The issue of medical chaperones is important whether one practises as a specialist, nurse, medical student, or generalist. This is repeatedly highlighted by newspapers and medical magazines where doctors (or nurses) have acted inappropriately. It often has life-changing repercussions for one or both parties [1,2].
Although chaperones have been used by doctors conducting intimate examinations for many years, there seems to be no uniformity as to how and when chaperones should be used varying considerably between countries [3]. In some countries such as New Zealand and the United Kingdom, chaperones are used routinely [4,5]. In other countries, such as Saudi Arabia, there is the potential influence of culture and religion [6], but in other countries, the use of chaperones remains largely unknown.
In Australia, there are no publications about the use of medical chaperones that relate to primary care where the vast majority of medical consultations occur. There is limited guidance from the Royal College of Australian General Practitioners (RACGP) [7]. In fact, the college raises the question about appropriateness and feasibility of the reported outcomes in general practice in Australia as most of the relevant research has been conducted overseas. It is thought that use of chaperones may be inherently different in Australia; in part due to a wide variation in clinician, patient, and public attitude and diverse cultural and religious influences. This qualitative study is the first attempt to try and gauge the attitudes and experiences of GPs (general practitioners) with Australia in respect to the use of chaperones.
Aim. To explore the attitudes and practices of a cohort of GPs practising in Melbourne, Australia, regarding the use of chaperones in general practice.

Method
2.1. Qualitative. Data were collected during two focus groups.
2.1.1. Recruitment. Seventeen GPs were recruited from two locations with different work patterns; ten volunteered in response to a poster advertisement at the Melbourne Metropolitan Deputising Service (MMDS), located in inner Melbourne. MMDS provides after-hours services throughout metropolitan Melbourne. Seven GPs volunteered in response to a seminar advertisement at Monash University Department of General Practice (MU) and also work in general practice, providing mostly daytime medical care. The number of participants in the focus groups was restricted to a maximum of 10 in each focus group.

Data
Collection. Data were collected using the semistructured interview schedule that was developed using the available literature. The schedule included prompts regarding the GPs' experiences of using a chaperone, possible influences and importance of using a chaperone, and any barriers. The two focus groups were held in April 2011, at MDDS (approximately 120 minutes) and Monash University, Department of General Practice (approximately 90 minutes). The focus groups were audio-taped and transcribed verbatim.

Data Analysis.
Data were analysed according to the Framework Method [8] which involves a process of becoming familiar with the content of the data, identifying recurring words and themes, and interpreting the themes to understand participants' perspectives [8][9][10]. Data were analysed independently by the two investigators; when there was a difference of opinion, the issues were discussed and agreement was reached. To ensure privacy and anonymity, statements are reported as either (MMDS) or (MU).

Ethics.
This study was approved by the Monash University Human Research Ethics committee (MUHREC). Written informed consent was obtained from each participant.

Demographics
3.1.1. MMDS. The ten GPs comprised seven males and three females, of those, six males and two females were born and trained overseas; the other male and female were born overseas and trained in Australia. One was less than 40 years and nine were aged 40+. Although currently living and working in Australia, all indicated a strong connection with what they described as their "country of origin." 3.1.2. MU. The seven GPs comprised three males and four females, of those, one female was born and trained overseas and indicated a strong connection to her country (i) Interpretation of "chaperone" (ii) Expectation of examination (iii) Chaperone availability (iv) Economic resources (v) Timing and the use of a chaperone of origin. The remainder were Australian born and trained, and described their connection as "Australian." All were aged 40+.
The findings and discussion are reported under the three main themes and sub-themes that emerged during the data analysis (see Table 1). The three main themes are grouped into those related to: (a) practitioner, (b) patient, (c) practice (workplace).

(a) Practitioner-Related
Background and Training of the GP. Opinion ranged about what may influence GPs. Some acknowledged that training and background of the GP as well as familiarity with Australian medical environment may influence the use of chaperones. Others felt that cultural or religious background may be potentially more significant than the country of training. Doctor-Patient Relationship. The groups acknowledge the importance of the doctor-patient relationship and the inherent power differential between doctor and patient and how this can vary between doctor and patient of dissimilar background. The artificial or formal nature of using a chaperone was raised, with the potential of distorting the consultation process and possibly impacting on doctorpatient relationship. Privacy and Confidentiality. Using chaperones in a small community or town highlighted the issue of privacy and confidentiality.

"If you work in a rural area in a smaller practice, everybody knows everybody, no one wants the receptionist to come in and chaperone (MU)." (c) Practice-Related
The Interpretation of the Term "Medical Chaperone." One issue raised in both groups concerned the meaning of "medical chaperone". Participants related that in most cases, a member of the practice staff would be considered as a medical chaperone. However, a chaperone in primary care may not necessarily have a health professional background. Also, unlike colleagues in the secondary care setting, GPs are sometimes required to attend patients at home or in a nursing home and are usually unaccompanied, particularly those working after-hours. On a home visit, the chaperone might be, for example, the GPs' driver or a medical student accompanying the GP.

"It's a difficult situation in the home visits, because you are literally unprotected if you do not have a chaperone there and it's you versus the patients (MMDS)." "I think in terms of general practice and out of hours, because we do home visits, we are at particular risk and it's about what is actually feasible because a chaperone might not always be feasible (MDDS)."
Expectations about Gynaecological Examinations. The group highlighted that often gynaecological examinations were carried out solely by female GPs. One issue subsequently highlighted the need for male GPs to maintain their level of confidence, professionalism, and skills by continuing to perform intimate examinations.

"A lot of female GPs [mainly do] the tears and smears (MU)."
"We are all trained to do medical examinations; if we do not do a gynae examination, breast examination, we won't know how to do a proper one (MMDS)." 3.2. Chaperone Availability. The provision of a chaperone may not be feasible in all circumstances in general practice in Australia for a number of reasons, for example, during home visits or because of the geographical outlay of Australia. Apart from GPs practising as sole practitioners, particularly in the outlying regions, some urban practices have no practice nurses; others only have a practice nurse for limited hours per day.
"Á place that has got a practice nurse and they come in once a week, it's totally different to one that's got a full time practice nurse (MU)."

Economic Costs.
Many participants echoed the economic implications of additional resources needed to implement chaperones but also raised issues such as keeping records about the offer and use of chaperones and the impact on the doctor-patient relationship. 3.4. Timing of Discussion and the Use of a Chaperone. GP participants related that some patients may not request a chaperone because they feel uncomfortable requesting a chaperone or might not know that such an option exists. GPs agreed that would be feasible for the clinic to arrange a chaperone if it was a scheduled procedure, for example, a Pap-smear. However, GPs also emphasised that offering a chaperone may be more useful in unanticipated intimate examinations.

Discussion
One of the most important components of the doctorpatient relationship is trust and respect for a patient's autonomy, and these can be expressed in different ways [11]. The power differentials that exist between doctors and their patients can be subtle, as can the vulnerability patients may feel. Thus, using a chaperone is both an added layer of protection and acknowledgement of a patient's vulnerability [1,4,12,13].
The main thrust of our findings highlights the main influences of the use of chaperones in this pilot group of Australian GPs (Table 1).
The group raised similar concerns and attitudes as international GP colleagues [14] but also added unique insight into local attitudes on the use of chaperones in general practice for example, the influence of diverse cultural influences from the Asia-Pacific region, the unique geographical setting of general practice in Australia and chaperone availability amongst others.
At the time of conducting this pilot study, the Medical Board of Australia (MBA) issued guidelines on sexual boundaries offering medical practitioners some clearer guidance [29]. While best practice may be for services to routinely offer a chaperone and record instances where an offer is declined, the provision of a chaperone may not be feasible in all circumstances-particularly in Australian general practice. Thus, flexible guidance is needed for general practice including doctors being urged to communicate more openly with patients about the use of chaperones [14]. For most patients, being reassured and given a choice of having the right to accept or decline the offer of a suitably qualified chaperone of their choice, takes precedence over the need for a chaperone [3,4,18].

Strengths and Limitations
This qualitative study is the first attempt to record the attitudes and experiences of GPs about their use of chaperones in general practice in Australia at a time when there was no formal guidance. While not all participants supported the idea of formal guidance, all agreed that further discussion and research from a wider audience are needed from an Australian perspective. From an international perspective, the use chaperones does not appear to have been explored, thus generally remains unknown, and what is known is limited to a handful of countries. This is odd since all primary International Journal of Family Medicine 5 care physicians will at some time in their career conduct an intimate examination. This provides an excellent template for other primary care clinicians to conduct research in this important field of doctor-patient relationship.
This pilot study made no attempt to recruit a truly representative sample of GPs practising in Australia. The study is limited to data from two focus groups and to GPs working in general practice and/or an after-hours medical deputising service in urban Melbourne. The views of other health-care workers and patients were not explored.

Implications for General Practice
This study is the first step in understanding the attitudes and experiences of GPs practising in Australia about the use of chaperones in general practice. There is a need to complement these views with a larger GP audience but also with patients who attend their general practitioner.