Going that extra mile

By Dr Jim Rodger, Head of Professional Services MDDUS

DOCTORS who display a warm, friendly and reassuring manner with their patients are more effective. There is no doubting the truth in this and research bears it out. Displaying appropriate empathy makes patients more open with symptoms and concerns and encourages them to become more engaged in their own treatment – all of which can lead to improved therapeutic outcomes.

But sometimes doctors can be too helpful. General practitioners, especially, develop close relationships with patients in both clinical and social terms. This is particularly so with patients who have serious or long-term illnesses. A natural increased level of compassion for people in difficult circumstances may blind the doctor to the risk of overly close involvement with matters that are not strictly clinical.

It is not a wish to eliminate any feelings of sympathy or empathy for patients since the job depends on that, but rather a word of caution about the ‘step too far’. To use another cliché, ‘going that extra mile’ for patients often backfires and confusingly causes more trouble for the doctor than they could ever imagine. We have examples of doctors who have gone to extraordinary lengths to see a patient referred, even hand-delivering letters to homes after work or offering to take patients in their own cars to appointments, then find a letter of complaint, to their astonishment, two weeks later.

Some doctors will take great pains to ensure access to weird and wonderful medicines that patients have read about or seen on the internet. They make efforts to see patients prescribed banned medicines (e.g. co-proxamol) despite all the legal and ethical advice to the contrary. It is not uncommon for patients to ask general practitioners to refer them to all sorts of ‘specialists’, and one doctor recently spent many hours searching for details of a person to whom the patient wished referred. The doctor was trying to find out the qualifications and registration of this individual to ensure that he was genuine and safe to refer to. He was absolutely right to try and check this information but it proved to be a major distraction and a time-consuming project.

Some doctors will try to give help and advice to families in relation to such matters as powers of attorney, capacity or incapacity, or the validity of wills. This must always be avoided; financial and other such personal concerns need professional legal advice, not that of a doctor. To become too closely involved in such matters risks being embroiled in legal proceedings – an issue of particular sensitivity now considering the legacy of Dr Shipman. Doctors may wish to be as helpful as they can but risk being thrust into the centre of family disputes.

There have been times when doctors, because of their concern for patients or their surviving carers, have thought to intervene in insurance claims which might be prejudiced by possible non-disclosure. All such reports must be factually true and supplied to an insurance company irrespective of their effects on the family. To do otherwise risks censure from an insurance company or ABPI or the GMC.

Custody battles between parents are another source of trouble for doctors. One may be pressured to take sides in such matters or asked to intervene on one side or the other. Too close involvement with the perceived rights or wrongs of these situations is dangerous. Both the parents’ and children’s futures are at stake and this has little, if anything, to do with clinical concerns. Parents must be directed to the right place to resolve these matters – a lawyer.

Finally, there have been examples of doctors who become embroiled in correspondence with a patient’s employer and decisions about suitability or otherwise for work or in relation to work-related illness. Unless a doctor has some special expertise in occupational medicine they should tread very carefully in fitness or otherwise for work, except in so far as they can comment in general terms.

Such dilemmas touch at the core of what it means to be a doctor. A recent article in the journal Social Theory and Health reports on analysis based on qualitative interviews of 52 doctors working in the NHS. The researchers were interested in assessing how the respondents “feel” about being a doctor. In summarising their findings the authors wrote:

“The feelings they [doctors] articulate are riven with ambivalence. We suggest that this is generated by a contextual tension which presumes that the medical profession are required to reproduce medicine as an abstract system – an objective, trustworthy, reliable, effective, competent and fair mode of healing – and yet individual practitioners are also required to be caring emotionally intelligent, intuitive, and sensitive.”1

This conclusion is hardly surprising. A healthy degree of emotional disengagement has been a tenent of medical professionalism since the days of Hippocrates. Today such “boundaries” are formalised in guidance from bodies such as the GMC. In 2006 the GMC released revised guidance on Maintaining Boundaries which warned that doctors must not use their professional position to establish or pursue improper emotional, including sexual, relationships with patients. The main issue for the GMC is one of trust.

“Trust is a critical component in the doctor-patient partnership: patients must be able to trust doctors with their lives and health. In most successful doctor-patient relationships a professional boundary exists between doctor and patient. If this boundary is breached, this can undermine the patient’s trust in their doctor, as well as the public’s trust in the medical profession.”

The guidance also comments on the potential “imbalance of power” in the doctor-patient relationship. Vulnerable patients can become over-reliant on doctors and it can be hard not to let this spill over into non-medical aspects of their lives.

This is not to suggest that overly helpful doctors are necessarily pursuing exploitative relationships with patients. It’s just that when therapeutic boundaries are blurred it can become a matter of perception. A patient’s overreliance can become dependence with a strong emotional component. Only so much can be covered in a seven minute (or even longer) consultation. This can lead to anger and hurt, and feelings of betrayal on the patient’s part when expectations are not met.

Getting too far drawn into the life of a patient can also raise questions of competence. The GMC’s Good Medical Practice states: “In providing care you must recognise and work within the limits of your competence”. Advising a patient on how to deal with financial debt may be tempting but it’s opening the door to criticism when things go wrong and the patient makes a complaint.

Doctors must also consider the effects on themselves of not maintaining a healthy emotional disengagement with patients. Burnout and compassion fatigue are real issues for general practitioners. Today much of the mental health treatment in the UK is provided in primary care. GPs are well suited to this role, having a holistic view of patients’ physical, social and psychological backgrounds. But some patients come with a seemingly insolvable tangle of interrelated problems. Trying to “take on” such patients can be both exhausting and thankless and often the best a doctor can hope for is to manage problems and conditions as they arise.

Some doctors may feel an ethical duty to sacrifice their own health and feelings for the good of their patients. This comes wrapped up in the vocational “call” to become a doctor. It is ironic but not surprising that these “good” doctors are those most susceptible to burnout and compassion fatigue.

Expectations placed on GPs can at times seem limitless. Only those able to manage these expectations and ‘fight the good fight’ but accept their limitations will avoid the common pitfalls of the profession.

• Dr Jim Rodger is a medico-legal adviser and head of professional services at MDDUS