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GPST editor Dr Peter Livingstone looks at the challenges of maintaining professional boundaries with patients in a digital age

THE first time a patient sent me a friend request on Facebook I remember being surprised that they would be remotely interested in seeing what I got up to in my spare time.

As a GP at a busy urban practice I see dozens of patients every week, some of whom attend regularly and I have come to know quite well. The doctor-patient relationship is a unique and privileged one. Mutual respect and trust are essential as we are privy to extremely sensitive, private information that our patient may never have shared with anyone else.

Despite this close relationship, it is vital to maintain boundaries and resist where possible the blurring of the personal and professional. In this respect it is important to remember that, as doctors, a greater degree of responsibility and influence still rests with us.

The GMC’s Good Medical Practice guidance is clear that “you must not use your professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them”. But the rise of social media (not to mention the use of other technology in healthcare such as email and mobile phones) has only served to increase the number of ways patients can connect with doctors and we must take a cautious approach.

In your own training you may have been asked by a patient to accept them as a Facebook “friend”. I have been asked a few times and politely declined each request. In one case this was followed by a challenging consultation where the patient was clearly annoyed. I tried to explain that, as their GP, it would be inappropriate to have them as a “friend” on Facebook but they seemed dissatisfied by my response and failed to see the need for such a professional boundary.

On reflection, society’s expectations of GPs and attitudes towards them are changing. I had never really thought about it until that consultation and it made me re-evaluate the way I use sites like Facebook. I never imagined patients would seek me out on social media but I quickly tightened up my privacy settings to make sure only friends could access my personal profile.

Connecting with patients at a personal level on these websites is fraught with difficulty. The BMA recommends that doctors (and medical students) should politely refuse any approach, providing an explanation as to why it would be inappropriate. Even with the most innocent of intentions, you run the risk of breaching patient confidentiality and of falling foul of the GMC’s rules on “improper” relationships with patients.

Maintaining these boundaries is a bit easier for those who work in bigger, urban practices and also if, like me, you live outside of your practice catchment area. But those who live and work in rural practices have to take extra care to avoid difficulties arising.

I remember growing up in a rural part of Northern Ireland where my father was the village GP, practising from home. We were an integrated part of our local community and everyone knew where we lived and had our home telephone number. The majority of my parents’ friends, and my school friends, were his patients and the house was always busy.

This was at a time where mobiles were still a rarity and social media was unheard of but GPs were regularly working on-call from home. It was very difficult for my parents to try and separate their personal and professional lives. If they wanted to go out for food and drink they would drive to another town or village. But if something ever needed fixed around the house, he’d always have to hire one of his patients to do it. What else could you do in a village when there was no one else to ask?!

If my father was still practising today, he may well be in the position of receiving Facebook requests from genuine friends who also happen to be his patients – a tricky situation many rural GPs will no doubt have to negotiate. In these circumstances, a doctor would have to exercise their professional judgement and common sense, being ever mindful of the need to maintain boundaries.

The RCGP published its Social Media Highway Code in 2012 which advised doctors to apply old fashioned “Wild West” principles when using social media. Medical professionals, the guidance said, should be guided by honesty, hospitality, fair play, loyalty, trust, consideration and respect in the same way as cowboys “in the frontier of the newly discovered Wild West”. The list of 10 rules encourages doctors to be aware of the image they present online, recognise that the personal and professional can’t always be separated and to engage with the public but be cautious of giving personal advice.

If we are able to adopt these principles we ensure that the risk of inappropriate patient contact is kept to a minimum.

Peter Livingstone is a GP and editor of GPST