Blurred boundaries

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.

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 she has started seeing someone who is a registered patient. She has treated the patient previously and recognises that the relationship could be seen as inappropriate. To mitigate any problems that might arise, she suggests that in future she will ask the patient to consult 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. She feels she cannot talk to her family and he didn’t want her to leave without support. She is now calling frequently to talk to him and appears to 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".

In Scenario 1 above, the GP should have considered whether accepting the gifts was in line with current guidance and, if so, 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. Dependent on the outcome of such a discussion, it may be appropriate to suggest that the patient see another GP in future.

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 2, the doctor entering into a relationship with her patient is very vulnerable to criticism. Even after a patient has left your care, you should think carefully before engaging in a personal relationship. With regard to such a scenario, GMC guidance advises doctors to consider the length of time since they treated the patient, how long their patient-clinician relationship lasted, the nature of the treatment, whether the patient could be considered vulnerable (then or now) and whether the doctor is still treating members of their family.

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.

It should also be recognised that contact via social media can add to the blurring of doctor-patient relationships as outlined here.

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/or 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.

ACTION POINTS

• Be cautious when providing personal contact details to patients and set clear boundaries on the purpose of sharing your information.
• Consider whether it may be appropriate to transfer care of an over-dependent patient to a colleague, although you may still have to treat the patient in an emergency.
• “Seek advice about your situation, from an impartial colleague, your defence body, or your medical association” (GMC) if unsure whether you are (or could be seen to be) abusing your professional position.

Liz Price is senior risk adviser at MDDUS