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Of all the ethical dilemmas doctors face, maintaining professional boundaries is among the most sensitive, for both patient and doctor. Medico-legal adviser, Dr Louise Dale, examines some of the issues in this area.
Instances of doctors allegedly breaching professional boundaries can be headline news and the painful consequences of an investigation can be extremely serious for a doctor, even when the allegations are proved to be unfounded.
In a recent 10-year period, the MDU opened over 700 advice files relating to medico-legal issues involving professional boundaries. Of these, 30% triggered a GMC investigation. While general practice represented just over half of the files, psychiatry, obstetrics and gynaecology, emergency medicine and general surgery also featured strongly. However, most specialties attracted at least one file relating to boundary issues in that period.
The doctor-patient relationship is almost always an intimate association where the normal boundaries of human social interaction are stretched, in terms of personal information given, with consent, and during examinations. The balance of power is more often tipped towards the doctor. Some patients are more emotionally or physically vulnerable to breaches of professional boundaries than others and, although this can be an obvious risk in some specialties, such as psychiatry, an imbalance of power can arise in any relationship between a doctor and patient.
Medical professionalism demands high standards of practice and the assiduous building of trust in the doctor-patient relationship. This dictates that the boundaries of professionalism must be respected at all times.
Although most often associated with improper emotional relationships or allegations of sexual impropriety, breaching professional boundaries can also encompass expressions of personal beliefs, financial conflicts of interest, and physical harm.
The GMC provides clear guidance on the diversity of boundary situations when a doctor might inadvertently, or deliberately, act unethically.
Maintaining Boundaries is specifically relevant to improper emotional relationships and sexual impropriety. In paragraph 4, the GMC says that: '...you must not use your professional position to establish or pursue a sexual or improper emotional relationship with a patient or someone close to them'.
Relationships with former patients may also be inappropriate and can lead to a GMC investigation. Such relationships may be considered inappropriate regardless of the time elapsed since the therapeutic relationship. The GMC does acknowledge that doctors may sometimes consider a sexual relationship with a former patient. In such circumstances it says that doctors must: '...use their professional judgement and give careful consideration to the nature and circumstances of the relationship'.
Some 40% of the files opened involved issues around the appropriate use of chaperones.
In Maintaining Boundaries, the GMC gives advice on intimate examinations and chaperones. It says that chaperones do not have to be medically qualified although, ideally, they should be familiar with the examination being performed and should be able to reassure the patient. If you are unsure about whether to use a chaperone, the GMC advises discussing your concerns confidentially with an impartial colleague, your medical defence organisation or the GMC itself.
Most doctors understand that there can be few, if any, situations where it can be appropriate to combine a professional and sexual relationship with a patient, and when the patient's feelings are not reciprocated great care must be taken to respond appropriately and not to inflame the situation.
Care should be taken if you become the subject of an amorous advance from a patient. Over a recent three-year period the MDU opened an average of one file every month from members who were worried about a patient's amorous attentions. Most doctors understand that there can be few, if any, situations where it can be appropriate to combine a professional and sexual relationship with a patient, and when the patient's feelings are not reciprocated great care must be taken to respond appropriately and not to inflame the situation.
The MDU generally advises the doctor to gently but unambiguously ask the patient to stop, explaining that because of the professional relationship between doctor and patient, any other type of relationship is not possible. However, if the patient persists, we advise members to keep records of the contacts and get in touch with the MDU for assistance as soon as possible.
The MDU is beginning to see more complaints and disciplinary matters arising from the use of social media. Doctors are expected to behave professionally in all aspects of their lives. One of the GMC's roles is to protect the public's trust in the medical profession and they may investigate a doctor's fitness to practise if a complaint is received about, for example, inappropriate language used on a social networking site, even if the comments are made in connection with a matter unrelated to their professional life.
Doctors may wish to exercise care when contacting patients using mobile phones and restrict calls to appropriate clinical matters, making a clear note of the discussion. Inappropriate use of mobile phones can lead to both disciplinary and regulatory investigation.
If a patient alleges that a doctor has behaved improperly, the doctor's employing trust will often act swiftly, possibly to suspend the doctor immediately, while it carries out an investigation. Sometimes, the trust will inform the police who may ask to interview the doctor under caution. The GMC may also be made aware, and a full investigation into the doctor's fitness to practise may follow. The investigations may take many months and are extremely stressful, with serious consequences for the doctor's professional and private life. One recent study has shown that trusts are inclined to punish doctors more strictly for misconduct than for underperformance. One reason may be that it is much more difficult to demonstrate remediation in a doctor's conduct than in underperformance. There are some specialised courses on boundary issues, such as those provided by The Clinic for Boundary Studies.
All doctors have a duty to raise concerns if they believe patients' safety or care is being compromised by the practice of colleagues, including where professional boundaries are being breached. The GMC may investigate doctors who do not act on their concerns in this regard.
Where possible, you should first raise a concern with the consultant in charge of a team, the clinical or medical director, or a post graduate dean if you are a doctor in training. If this is not possible, or you feel the responsible person or body has not taken adequate action, you may wish to report your concerns to the GMC. If you are not sure whether, or how, to raise a concern, you can ask the MDU for advice. The charity Public Concern at Work also provides free, confidential legal advice on raising concerns.
Trust in our profession remains very high. However, the MDU continues to open files concerning complaints, disciplinary, regulatory and even criminal investigations arising from allegations of breach of professional boundaries.
If you have concerns about specific medico-legal issues related to professional boundaries, please contact the MDU 24-hour helpline on 0800 716 646.
A 40-year old female patient attended casualty complaining of shortness of breath. The A&E consultant carried out a routine chest examination before admitting the patient to a medical ward for further investigation and treatment. The following day, the consultant was suspended. He was told it was a neutral act while the trust investigated the patient's complaint that he had inappropriately touched her breasts. The trust manager warned the doctor that the police might be informed.
The doctor vigorously denied the allegation and immediately contacted the MDU for advice. He explained to the medico-legal adviser that he had been very busy and had seen the patient alone, not having had time to find a suitable chaperone.
Within the next week, the doctor was called to a police interview under caution. An MDU-instructed solicitor accompanied him. A few weeks later, he attended a trust investigatory meeting, again supported by an MDU representative. He then received a letter from the GMC indicating that he was now under a full investigation into his fitness to practise.
The Crown Prosecution Service subsequently decided not to charge the doctor, as a family member came forward and gave evidence that the patient had in fact made similar allegations against a family friend and a dentist in the past. However, the doctor had now become unwell as a result of the stress of the suspension and the allegations, and the effect this was also having on his family.
The trust eventually closed their disciplinary investigation. The MDU continued to support the doctor through a long GMC investigation, that by now required him to undergo GMC medical examinations.
Eighteen months later, the doctor returned to work, with undertakings imposed by the GMC that included reports from his own treating GP for a further 18 months.
This is a fictional case compiled from actual cases in the MDU files.
Abuse of the doctor-patient relationship (2010). Subotsky, Bewley and Crowe. RCPsych.
This article originally appeared in the printed edition of the MDU journal April 2013 entitled "Maintaining boundaries"
This guidance was correct at publication . It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.
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