Around 7% of allegations heard at fitness-to-practise hearings in 2011 were with regards to relationships with patients. As a doctor’s profession is defined by the duty of care to patients, it follows that standards of professionalism are entwined with the strength of the relationship between doctor and patient.
But this relationship doesn’t just concern your clinical work – good communication, politeness and respect, and a caring, empathic manner are all vital components of an effective doctor–patient relationship. Similarly, avoiding allowing this relationship to descend into something less appropriate is the correct, and professional, approach.
"Managing the relationship with patients also means respecting their right to confidentiality and maintaining professional boundaries"
MPS has written extensively on the importance of good communication, partly due to the oft-quoted fact that 70% of litigation in healthcare is related to poor communication. Read the article, Good communication: why it's worth it, Sessional GP, Issue 1, October 2009.
Another aspect of good communication is being honest and open when things go wrong. Good Medical Practice says, in paragraph 55: “You must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress, you should:
(a) put matters right (if that is possible)
(b) offer an apology
(c) explain fully and promptly what has happened and the likely short-term and long-term effects.”
For more on being open, see Chapter 4, “What to do when things go wrong”.
"Be aware of how you portray yourself to patients"
Managing the relationship with patients also means respecting their right to confidentiality and maintaining professional boundaries. While doctors are rightly expected to show compassion and empathy when treating patients, it is undoubtedly a challenge to show this human face without blurring the boundary between professional and personal relationships. The GMC has published detailed guidance on maintaining boundaries in Sexual behaviour and your duty to report colleagues (2013).
Knowing how to maintain this boundary depends largely on a doctor’s self-awareness and their ability to judge the particular situation. A reassuring hug, for example, depends largely on the pre-existing familiarity between doctor and patient. You should also be aware of cultural differences and whether or not an interpreter is necessary. Your best protection is to know yourself: become adept at identifying and monitoring your feelings towards your patients (whether these are negative or positive).
- Be aware of how you portray yourself to patients.
- Do you feel uncomfortable with a patient? If so, try to identify the cause – is it something they said, or did, or was it their body language?
- Do you feel a special rapport or sexual attraction to a particular patient? If so, seek advice from a colleague and deal with the situation before it escalates, either by establishing clear professional boundaries and sticking to them, or by referring the patient’s care to another doctor.
Social media
Being aware of professional boundaries also extends to doctors’ use of social media. It is now practically ever-present in people’s lives, and doctors should be particularly aware of the risks. There have been numerous examples in the media about doctors revealing confidential patient information on blogs, Facebook, Twitter and other forums, while doctors who fail to restrict access to their private lives – and the particularly unsavoury photographs or videos that are a common feature for some – risk damaging their professional image.
MPS advice is that doctors should treat everything posted to social networks as if it is something they have written down – it is never truly anonymous and exists in perpetuity, meaning that the chances of such comments being traced to the author should never be disregarded. Comments made innocently about patients, treatments or particular procedures can potentially breach confidentiality, especially if they mention unusual symptoms or conditions – if just one patient recognised themselves from your comments, it is likely to be sufficient for the GMC to take action.
Social media is a new arena within which doctors must tread carefully, being mindful of their responsibility to maintain public trust and the standing of the profession. It is for this reason that MPS strongly advises doctors to avoid adding patients as “friends” on sites such as Facebook.
The GMC has published explanatory guidance on this topic – Doctors’ use of social media (2013).
CASE STUDY: After hours
Doctors are expected to be empathic and compassionate towards patients – but this emotional involvement must be managed carefully if the hallowed boundaries between doctor and patient are to be maintained.
Dr Evans was a GP registrar who had been working at his current surgery for two years. The surgery was owned by two well-respected partners who had practised in the village for more than 30 years.
Dr Evans, who was married, occasionally stayed late in the surgery, where he was usually joined by healthcare assistant Debbie as the only other member of staff in the building. Debbie was also a patient at the surgery and had consulted Dr Evans on at least a couple of occasions.
Around six months after Dr Evans began working late, his wife accidentally discovered text messages from another woman on his mobile phone. They were of a flirtatious and sexual nature. It soon emerged that the texts were from Debbie and that Dr Evans had been having sexual relations with her in the practice, during their evening work.
Ashamed, Dr Evans reported the affair to the partners and eventually resigned. He was reported to the GMC and faced a fitness-to-practise hearing, where he was suspended for a year and had several restrictions placed on his practice.
MPS advice: The GMC is clear that doctors should not pursue sexual or improper emotional relations with patients. There are many instances in which doctors have become entangled in their own strong emotional responses to a patient, and this can become further complicated if the patient is also a work colleague, with whom you share large amounts of time and a sense of camaraderie.
But although doctors such as Dr Evans would not describe themselves as predatory or exploitative, the fact is that power in the doctor–patient relationship is inherently unequal and to pursue those feelings would be unethical. Recognising the early warning signs is, therefore, crucial. These include:
- Frequently thinking about the patient on a personal level
- Looking forward to seeing the patient with a sense of anticipation
- Allowing consultations to run over, even though there is no clinical reason for it
- Giving the patient preferential treatment – eg, cutting another patient’s consultation short to make room for them, expediting a referral for non-clinical reasons
- Treating the patient as “special” – eg, showing unusual deference, divulging personal information about yourself
- Creating opportunities to see the patient.
Some of this advice is taken from the Casebook article "Drawing the line”, by Sandy Anthony and Sara Williams (Vol 16 No 2 – May 2008).