Risk: Detached but personal

MDDUS advisers often hear from members concerned that the professional boundary with a patient has become blurred. It can be tricky to remain detached from patients, particularly in the early stages of your career. You may share a hobby in common or may have treated someone through a very traumatic illness or distressing period. You may also know a patient well as a member of a small local community.

These and other circumstances can be the starting point of a potentially "unprofessional" relationship and, without realising, you may find yourself in difficulty in regard to regulatory guidance or, at least, under pressure with additional workload or demands on your time with that patient.

Consider these examples:

1. A GP accepts a small gift from a patient who is grateful to him for treating her elderly parent. He then finds that she starts to bring more gifts which, over time, start to increase in value. The GP doesn’t want to offend the patient but feels that the nature of their relationship is changing and that by continuing to accept the gifts he is perhaps encouraging something unintended.
2. A GP colleague has disclosed that he has started seeing someone who is the mother of a registered patient. He has treated the patient previously and recognises that the relationship could be seen as inappropriate. To mitigate any problems that might arise, he suggests that in future he will ask that the patient consults with other doctors in the practice.
3. A trainee has shared his mobile phone number with a patient experiencing symptoms of depression, as at their last consultation she had become very distressed. The patient feels she cannot talk to her family and the GP didn’t want her to leave without support. She is now calling frequently to talk to him and appears to be becoming dependent.

It can be difficult to identify the point at which a patient-doctor relationship starts to blur, particularly for GPs who often have longstanding relationships with patients, or other clinicians treating vulnerable patients with mental health issues.

GMC guidance Maintaining a professional boundary between you and your patient states: "If a patient pursues a sexual or improper emotional relationship with you, you should treat them politely and considerately and try to re-establish a professional boundary. If trust has broken down and you find it necessary to end the professional relationship, you must follow the GMC guidance: Ending your professional relationship with a patient".

GMC guidance also states that: "You must not pursue a sexual or improper emotional relationship with a current patient” and goes on to say that doctors “must not end a professional relationship with a patient solely to pursue a personal relationship with them".

In Scenario 1 above, the GP should have considered whether accepting the gifts was in line with current guidance and, if not, he would most likely have politely declined at an earlier point in time. At this point, he could have explained his concerns to the patient. Whilst having this conversation might be embarrassing, it ensures that, whether or not such concerns are founded, there is now the opportunity to reinforce professional obligations to the patient and restate the boundaries of the relationship.

In Scenario 2, the doctor entering into a relationship with the family member of a patient is vulnerable to significant criticism and regulatory action. Even after a patient has left your care, you should think carefully before engaging in such a personal relationship. GMC guidance advises doctors to consider the length of time since they treated the patient, how long the patient-clinician relationship lasted and the nature of the treatment and whether the patient or family member could be considered vulnerable (then or now).

Considering Scenario 3, there may be circumstances (although not advisable) where a doctor determines it is appropriate to disclose personal contact information to a patient – and patients may see this as good service. In this type of situation, it could possibly have been foreseen that the patient may become dependent. The doctor should seek advice from his trainer, who may decide to intervene – ensuring that the patient is aware of alternative mechanisms of accessing support and the boundaries of the doctor-patient relationship.

MDDUS has all too often seen these types of cases result in complaints against the doctor, particularly if a patient perceives that the doctor is withdrawing support, or if they feel embarrassed about their part in the situation.

Recognising early warning signs and seeking the views of partners/senior colleagues and MDDUS is advised. Approaching situations as soon as concerns are highlighted, with great care and sensitivity, can prevent a breakdown of the doctor-patient relationship and ensure that boundaries remain clear.

Liz Price is senior risk adviser at MDDUS