An improper relationship?

TRUST is the foundation of the doctor-patient partnership. There is a clear public interest in patients being assured their doctor will behave professionally towards them. While this is a familiar concept for doctors in relation to issues of confidentiality, it is also vital patients can trust doctors will behave professionally during consultations and will not view them as potential sexual partners.

Consider the following scenario:

It was a girls’ night out to celebrate our exam success and the end of GP training. After a meal and drinks we headed to the local nightclub – and that’s where I met Mark. We got on well and afterwards he said he would find me on Facebook. I thought no more about it until he appeared in my surgery two weeks later with a knee injury from football. I took a history, examined him and gave him the appropriate advice on rest, ice and elevation and he asked if that meant no more dancing. I said “yes” and he asked if I would have dinner with him instead. I was flustered. I liked him and if he had asked me in the club I would have said yes… but now we had met in the surgery, what was I to do?

The General Medical Council offers guidance on this area in Good Medical Practice, as well as its supplementary guidance Maintaining a professional boundary between you and your patient, and Sexual behaviour and your duty to report colleagues.

The message to doctors is clear: “You must not use your professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them.”

It would be improper, for example, to arrange regular reviews of a child purely to develop a relationship with the parent, or to make a home visit to an elderly man in order to see more of his son. The word “must” is used by the GMC to emphasise an overriding duty and any failure to follow this will result in a doctor’s registration being put at risk.

Unwanted attention

It can be difficult when a patient makes unwanted advances and MDDUS has received calls from doctors who have been given letters or gifts or invitations by patients whose motives are not quite clear. It is always good practice to respond politely and considerately and to try to reestablish the professional boundary, explaining it is not appropriate for a doctor to have that type of relationship with a patient. Seeking help from a neutral person such as the practice manager or senior partner can also be useful.

For extra clarity, it may be appropriate to write a letter of response to the patient (with help from MDDUS) gently pointing out that this type of behaviour is not acceptable. In extreme cases, where a doctor feels that trust has completely broken down, then a decision can be taken to end the doctor-patient relationship and remove the patient from your list. If so, you must take care to follow the relevant guidance and it is advisable to discuss the matter first with an MDDUS adviser.

Judgement call

It is clear that pursuing a relationship with a current patient or their relative is not a good idea but what about a former patient, one who has left the list?

The answer is: it depends. And it depends on a combination of factors such as the length of time since the professional relationship ended; the nature of the professional relationship; whether the patient was particularly vulnerable at the time you were seeing them as a doctor; and whether you will be caring for other members of the patient’s family.

There is no magic number of days or weeks since a patient left your practice that constitutes an acceptable timescale for you to pursue a relationship. The key factor to consider is whether the relationship you are pursuing is, or can be seen to be, an abuse of power and your position of trust. Common sense would suggest that if you start a relationship with a patient you have seen once, there is far less chance of you being accused of abusing your position than with someone you have seen repeatedly over a period of years.

An abuse of power is more likely to be an issue when the patient is vulnerable. Some patients are more vulnerable than others, particularly patients with mental health problems.

Raising concerns

It is also important to be aware that if a patient discloses to you that a fellow doctor has made inappropriate advances towards them you must promptly report your concerns to the relevant person or organisation who will investigate the allegation. Bear in mind that sexual behaviour does not exclusively involve touching and would include inappropriate sexual comments.

Equally, if you think a sexual assault has taken place then this should be reported to the police. The best approach is to first discuss the matter with the patient and encourage them to disclose the information themselves. If they refuse and you believe there is a public interest in making the disclosure, you should seek their consent to do so. In exceptional cases, where a patient withholds consent but you believe a disclosure should be made to protect other patients/the public from risks of serious harm, this can still be done without permission. In these instances, only the minimum information necessary should be disclosed and the patient should be informed. (See the GMC’s Confidentiality guidance.)

Trainee dilemma

So what should our GP trainee do about Mark’s dinner invitation?

Well the guidance is clear that doctors should not pursue a relationship with a patient, nor should she ask him to leave the list so that she can do so. However, she did meet him first socially, before he became her patient, and she was due to leave her training practice in two weeks’ time. Considering these circumstances, she was advised to check how long Mark has been a patient with the practice to make sure he did not register there specifically to make contact with her. She should also check that he is not vulnerable. Assuming both of these factors were in order, she could reasonably accept his dinner invitation after finishing her placement at the practice. She would also have to be clear that she could not see him as a patient again.

Dr Susan Gibson-Smith is a medical adviser at MDDUS