Blurring the boundaries

FEW would argue that the way we interact, in all aspects of our life, is in a state of flux. The ever-rising use of social media means we rely less on face-to-face contact, interacting via digital platforms such as Twitter, Facebook, WhatsApp or Instagram. Behaviours that in the past might have been tolerated or even accepted as appropriate interaction are now being challenged.

The dentist-patient professional relationship has also seen radical change in the UK over several decades, with a marked departure from medical paternalism to the autonomous patient. Throughout all of this change, we are obliged to navigate the complexities of human interaction whilst maintaining professional boundaries.

As dentists, we often see patients at their most vulnerable, in pain and nervous, facing necessary procedures. The treatment we provide is by nature invasive, probing into the intimate body space of a conscious patient who cannot see what we are doing. Good communication is key to gaining patient trust in such a precarious situation. It is important to give the profession credit in overcoming this challenge on a daily basis.

JUSTIFIED TRUST

Professional boundaries can be defined as those "between what is acceptable and unacceptable for a professional to do, both at work and outside it, and also the boundaries of a professional’s practice".¹ These boundaries exist to protect both the patient and the professional. Professionalism is a dynamic concept – given the variety of dentist-patient interactions – to which we must pay careful attention in order to manage the interface between our personal and professional selves. It can be difficult to absolutely define what is and what is not professional. In its guidance, Standards for the dental team, the GDC asks that you "ensure that your conduct, both at work and in your personal life, justifies patients’ trust in you and the public’s trust in the dental profession".²

All health and social care professionals are expected to maintain professional boundaries. Research appearing in the British Journal of Social Work found that rather than relying on professional codes of practice, a clear majority of social workers relied on their own sense of what is appropriate or inappropriate, and made their judgements with no reference to any formal guidance¹. Making such a judgement comes with an assumption that we can always determine for ourselves what is appropriate, even at potentially turbulent times in our life. It is of note that dentists involved in regulatory proceedings due to a breach in professional boundaries have often been facing difficulties in their personal life.

PATIENT BOUNDARIES

The GDC states: "You must maintain appropriate boundaries in the relationships you have with patients. You must not take advantage of your position as a dental professional in your relationships with patients".²

In some circumstances you might be the health professional that a patient sees most often, especially if a regular attender at the dental surgery. Patients may offload information about their personal lives during chair-side conversations and, whilst you would want them to feel relaxed and at ease, it is still important to maintain a professional distance. It is therefore wise not to share personal information about your own life.

You should not accept "friend requests" from patients on social media sites, and if you are concerned that a patient is making inappropriate advances, you should politely remind them that your relationship is strictly professional and document that discussion. In such circumstances you may need to suggest that the patient is treated by another colleague in future (unless in an emergency).

MDDUS has found that when boundaries become blurred and a patient is communicating with a dentist via text or social media there is always the risk that a “platonic” relationship can turn sour, especially if treatment problems are encountered. Any resulting complaint could soon escalate with the dentist facing criticism for not maintaining professional boundaries.

Professionalism is, again, a dynamic concept and adaptation may be required in dentist-patient relationships, for example with cultural differences. On the European continent, kisses on the cheek when greeting might be commonplace but they would likely take UK patients by surprise. Equally some patients might not feel comfortable shaking hands. Patients should therefore be treated as individuals and our interactions measured accordingly.

AMONG COLLEAGUES

Successful dental practices depend on colleagues working closely together. We rely on each other when navigating our day list and looking after patients. “Getting on” is crucial to this working relationship and friendships often develop. However, it is still important to maintain a professional working relationship. An increasingly common cause for GDC investigations is a business or employment dispute which has turned particularly sour. One dentist or dental care professional complains about the other to the GDC and, frequently, both or multiple professionals end up being drawn into the investigation. In a similar way, an inappropriate relationship between colleagues can end up being aired at a regulatory hearing.

Some cases may involve a dentist providing treatment to a colleague; this is not precluded but should be approached with caution. In such situations, clinical judgment may become too subjective, which means we might not be treating a colleague as we would other patients. We still need to fully assess the patient, reach a diagnosis, give treatment options, gain valid consent, document everything in the clinical notes and provide treatment which is in their best interests. Knowing the patient in a professional context means we may not be as rigorous in following usual routines and, in such cases, it may be sensible for the colleague to seek treatment elsewhere.

SOCIAL MEDIA

Social media is now almost inescapable, infiltrating most of our lives. Personal information can enter the public domain and leave an indelible mark on a dentist’s professional reputation. GMC guidance on Maintaining a professional boundary between you and your patient states: “Social media can blur the boundaries between a doctor’s personal and professional lives and may change the relationship between a doctor and patient”.³

GDC guidance states that "when using social media, you must maintain appropriate boundaries in the relationships you have with patients and other members of the dental team”, and that social media has “blurred the boundaries between public and private life, and your online image can impact on your professional life".⁴

A dentist should therefore always give very careful consideration to anything they choose to post on a public or private online forum. Social media might be disclosed during the course of a GDC hearing as evidence relating to an inappropriate interaction with either a patient or a colleague. Boundaries can also become blurred when personal telephone numbers or websites are used to communicate with patients. Patients should always be asked to communicate through practice portals.

The digital age has created a more fluid environment for social exchange in general. We must therefore pay careful attention in order to manage the boundaries between our personal and professional selves, and in doing so avoid blurring those boundaries.

Sarah Harford is a dental adviser at MDDUS

REFERENCES

1 Doel Mark, et al. 2010 Professional boundaries: crossing a line or entering the shadows? British Journal of Social work 40 (6): 1866-1889

2 General Dental Council 2013 Standards for the dental team

3 General Medical Council 2013 Maintaining a professional boundary between you and your patient

4 General Dental Council 2016 Guidance on using social media