A breakdown in communications; finger on the pulse

A few years ago, the indecent assault of a female patient by a female doctor would have seemed not only unthinkable but also implausible. And yet, earlier this year, just such a case arose. Thank goodness, the doctor was cleared of all charges, but it caused me to consider whether I should ask for what is called a "chaperone" every time I examine a patient, regardless of their sex.

The Medical Defence Union, which provides legal representation for the medical profession, recommends that both men and women doctors protect themselves by making sure a chaperone is present for intimate examinations. The Medical Protection Society defines a chaperone as "someone with nothing to gain by misinterpreting the facts". Relatives of the patient are therefore disqualified, which only leaves a nurse or receptionist who can be trusted to maintain confidentiality.

It had never occurred to me to equip myself with a chaperone for my same- sex patients - or, indeed, for my male patients. I assumed I would never be in a position where the trust between the patient and myself was at risk or could be misinterpreted. Thinking about it, I was probably naive. But would it be practical to use a chaperone for every consultation? Take a busy Monday morning. The waiting room is heaving and there are five doctors working flat out, each needing instant access to a chaperone. Who would provide this service and at what cost? Confidentiality would be another casualty. I can think of several very difficult consultations that would have been impossible with a third party present. The patients trusted me and could talk about their concerns.

Do patients still trust their doctor? Maybe we've become too friendly and built up relationships which can be misinterpreted. Perhaps we should go back to the days when doctors sat across a wide desk, doling out advice and tablets but never thinking to ask the patient what they thought was wrong. Today, most doctors feel a partnership with their patients is more fruitful than the paternalistic approach of the past. (Although, at least then patients believed what their doctor told them!)

At medical school, we weren't tutored in the art of communication, but we were given sessions on consultation skills during my GP training. I remember one of these sessions well. It was called, "How to end a consultation swiftly and recognise when the patient doesn't seem to be picking up the clues." This was a game of strategy for two players. You are coming to the end of your consultation: and want to get rid of your patient. Step one: put your pen down. Step two: close the notes and ask yourself the question, "Has the patient noticed this?" If the answer is no, proceed to step three: throw the notes on the floor (usually a fairly obvious clue that you have finished). If the patient is still talking, move on to step 4: get up and open the door, take the patient by the arm and escort them to the reception area. If they are still talking, politely but speedily pass them over to the receptionist, tell him or her that Mrs X needs another appointment, walk swiftly back to your room and close the door firmly. Easy with practice.

Of course, this is really very bad communication - but we all do it at times. I still believe that trust comes from good communication. It's better to be too friendly to a patient than risk being perceived as being aloof. This, I think, could be misinterpreted as not caring - a far worse sin to commit.