A step too far?

Maintaining appropriate boundaries with patients is a key obligation for doctors and other healthcare professionals – but would you recognise a GP overstepping the mark? Dr Naeem Nazem offers some advice

HEALTHCARE professionals should always be aware of their privileged position in society. There are few professions in which you can question an individual on the most personal aspects of their life, let alone examine them or perform invasive procedures. People allow their doctor or dentist or practice nurse this liberty in order to receive appropriate treatment. In return they trust professionals not to abuse their position. And therein lies the cornerstone of any patient relationship: trust.

Below are some points to consider when establishing practice policies which support maintaining appropriate boundaries with patients.

A FRIEND IN NEED

Any doctor would help a stranger on the street suffering a medical emergency and MDDUS provides access to indemnity for such “Good Samaritan acts”. And if a nonpatient arrived at the practice door needing immediate assistance, the practice should at minimum assess their need and treat/ signpost as appropriate. However, what happens when the situation is not as clear?

Consider the scenario: a GP meets up with a friend on a Friday evening. The friend is going on holiday on Monday and forgot to pick up her repeat prescription for thyroxine medication, which will now run out during the trip. Her practice is closed for the weekend so she asks her friend to write the prescription. What should the GP do?

The GMC states that doctors should, wherever possible, avoid providing medical care to friends or relatives unless in an emergency. But does this scenario qualify as an emergency? After all, the friend is unable to collect the prescription before going on holiday so it is an urgent situation for her. Or perhaps it could be argued she is just a friend and not someone “close” to the GP?

Although one or more of the arguments above may seem persuasive, the GMC’s guidance does start by saying “wherever possible”, implying that a GP should exclude all the other possibilities before making a decision to treat or prescribe. In this case there are lots of other options available. For example, the friend could attend one of the many walk-in centres in the UK that are open at weekends. Or she could see a doctor in the country she is visiting and obtain a local prescription. In this case, by issuing the prescription, the GP is likely not only to fall foul of the GMC’s guidance, but also local prescribing policies and restrictions.

A FRIEND REQUEST

When it comes to maintaining boundaries, another important risk area is social media. Patients can often form close bonds with their doctor or dentist and many are tempted to look them up on Facebook and may even send a friend request. So what should a GP or dentist do upon receiving a request from a patient? Is it okay to accept? Or should these be declined even if it leads to potentially awkward moments later?

Declining a friend request may be awkward but how might a doctor or dentist feel knowing a patient had seen personal photos and details of friends and family – or that they had read personal comments posted or received on Facebook? Would it make discussing treatment plans or delicate decisions more difficult? Would it impact the level of professional trust?

The GMC’s guidance Doctors’ use of social media advises that using social media creates risks, “particularly where social and professional boundaries become unclear”. It goes on: “If a patient contacts you about their care or other professional matters through your private profile, you should indicate that you cannot mix social and professional relationships and, where appropriate, direct them to your professional profile”.

MDDUS recommends that doctors and dentists decline friend requests and, if the matter is raised by a patient, offer a polite explanation of the importance of maintaining a strictly professional relationship. If a patient persists in seeking to engage via social media it may be helpful to discuss the matter with the practice team. As with nearly all difficult situations, it is also essential to keep a clear record of everything that is happening at the time it happens. It is also worth highlighting to clinicians and other practice staff that they can take steps to minimise the chances of patients making contact via social media. Offering guidance to ensure privacy settings are as secure as possible and trying to keep a clear line between professional and personal pages are important.

MORE THAN A FRIEND

Another dilemma for some practices is whether it is ever appropriate for a doctor or dentist to become romantically involved with a patient, either past or present. As highlighted at the outset, trust is the foundation of any patient relationship. The GMC is clear that a personal relationship with a current patient is never acceptable. Doctors must never use their professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them. GMC guidance Maintaining a professional boundary between you and your patient also states that doctors must not end a professional relationship with a patient solely to pursue a personal relationship with them.

The GDC in its Standards for the Dental Team also 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.”

But is it ever appropriate for doctors or dentists to become involved with former patients? There are no answers or set time limits in such situations and clinicians must always exercise their judgement. The GMC explains that the more recently a professional relationship with a patient ended, the less likely it is that beginning a personal relationship with that patient would be appropriate. The duration of the professional relationship may also be relevant. For example, a relationship with a former patient treated over a number of years is more likely to be inappropriate than a relationship with a patient seen in a single consultation. Much also depends on whether there could be any perceived abuse of position. Factors to consider include the amount of time since the patient was last seen in a consultation, whether they are vulnerable and whether family members are still under treatment.

IN SUMMARY

Having practice policies in place can help highlight and reduce risks associated with these types of situations. In addition, practice managers can play a role in ensuring a practice culture exists in which staff are able to discuss openly any concerns they have about relationships with patients and approaches from patients, knowing that they will be supported in how to deal with these mindfully and safely.

Dr Naeem Nazem is a medical adviser at MDDUS