Strictly professional

DOCTORS have a privileged position in society and their work gives them privileged access to patients, some of whom may be very vulnerable. In its core guidance for doctors Good Medical Practice, the General Medical Council categorically advises doctors that: “You must not use your professional position to establish or pursue a sexual or improper emotional relationship with a patient or someone close to them”.

In November 2006 the GMC expanded on this advice in a more comprehensive guidance document entitled Maintaining Boundaries. The guidance reflects changing attitudes towards the doctor-patient relationship. Long gone are the days of unquestioned reverence for those in the medical profession. Society now views the doctor-patient relationship as a twoway process and expects that respect will be shown on both sides. But in a relationship which makes mutual demands, it is important to remember that a greater degree of both responsibility and power still rests with the doctor.

In its expanded guidance the GMC recognises this potential imbalance of power and emphasises that an appropriate professional boundary is essential to ensure the maintenance of trust, both in terms of the individual doctorpatient relationship and also the general trust that the public at large should be able to have in the medical profession.

Abuse of trust

The potential for doctors to abuse this power in some cases is abundantly clear. For example, a patient may be either physically or emotionally vulnerable, or the doctor may control access to healthcare resources that the patient is reliant upon. Few doctors would doubt that a sexual relationship with a young or mentally troubled patient could lead to very serious professional consequences. The GMC has stated that a doctor whose conduct has shown that they cannot justify the trust placed in them should not continue in unrestricted practice.

But is this true of any relationship with a patient outside a therapeutic context? Certainly the requirement of a professional boundary is widely interpreted and it is important to understand that the GMC may still question a doctor’s fitness to practise even if the relationship, on the face of it, is an entirely open and consensual one with no obvious adverse consequences for the patient. The relationship need not be long-term or sexual in nature to attract censure.

One case considered by the GMC’s fitness to practise panel involved a male doctor who examined a female patient in accident and emergency and developed a personal relationship with her. The fitness to practise panel determined that the doctor’s actions in giving the patient his personal mobile telephone number, responding to her text messages on matters unconnected with her medical condition, and engaging in flirtatious text messaging and conversation with her, whilst being a medical practitioner responsible for her clinical care, were inappropriate and an abuse of his position as a registered medical practitioner.

Timing and other factors

A common misconception is that relationships with former patients are unproblematic, provided the therapeutic relationship has come to an end. This is not always the case. Even where the relationship does not develop beyond the realms of a doctor-patient one until a considerable time after the provision of clinical care has ceased, there is still considered to be a risk that the previous professional relationship may be abused. For this reason it is unlikely that pursuing a sexual relationship with a former patient who was vulnerable for any reason at the time of the therapeutic relationship, will ever be considered acceptable.

Similar problems can emerge if a doctor uses a professional relationship with a patient to pursue a relationship with someone close to that patient. The GMC makes it clear that a doctor “must not use home visits to pursue a relationship with a member of a patient’s family.”

Doctors who regularly encounter patients in a social setting – such as those practising in rural areas – may need to take extra care to avoid difficulties arising. The GMC suggests in Maintaining Boundaries that if social contact with a former patient leads to the possibility of a sexual relationship beginning, doctors should use their professional judgement and give careful consideration to the nature and circumstances of the relationship, taking account of the following factors:

• duration of the professional relationship and when it ended

• nature of the previous professional relationship

• degree to which the patient is, or was at the time of the professional relationship, vulnerable

• whether the doctor will be caring for other members of the patient’s family.

Doctors not only have a responsibility for their own conduct when it comes to inappropriate relationships or behaviour, the GMC expects vigilance in relation to colleagues. Maintaining Boundaries states that if you have reason to believe a colleague has, or might have demonstrated sexual behaviour when with a patient “you must take appropriate steps without delay so that your concerns are investigated and patients protected where necessary”. Advice on what steps to take can be found in the GMC’s Good Medical Practice;Management for doctors and Raising concerns about patient safety.

Keep it professional

Conversely, if a patient makes sexual comments or advances towards their doctor, the practitioner is advised by the GMC to treat the person “politely and considerately” and make attempts to reestablish a professional boundary. In extreme cases it may be necessary to end the professional relationship with the patient concerned, but doctors should always refer to GMC guidance before taking this step.

In considering the appropriateness of any relationship with a patient, doctors should be mindful not only of whether they are abusing their professional position, but of whether they could be seen to be doing so. It is suggested that doctors take great care in making such judgements. Any member who is not sure whether a relationship could be viewed as an abuse of their professional position can seek advice from MDDUS. Alternatively, discussion with an impartial colleague or adviser is to be greatly encouraged.

The message is this: regardless of how natural the start of a new relationship may seem, doctors should remind themselves of the standards expected of them. An appropriate boundary with patients must always be maintained if professional integrity is to remain intact.

Denise McVeigh is a solicitor at MDDUS