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BOUNDARIES WITH PATIENTS
Patients trust doctors; when asked which professions the public trust most to tell the truth, a recent poll showed that nurses top the poll at 94% and doctors come second at 91% (Ipsos 2019).The GMC highlights maintaining trust as one of the four domains highlighted in the Duties of a Doctor (GMC: 2013). This domain is one that you will discuss in your appraisal with your appraiser.
A trusting relationship is essential to effective medical practice yet the relationship has been traditionally characterised by an imbalance of power, doctors have knowledge, skills and expertise that the patient frequently does not and patients are often vulnerable, physically and emotionally when unwell; some patients are especially vulnerable because of their illness, disability or frailty, children and young people under 18 years can be particularly vulnerable (GMC 2013, RCP 2007). Most patients do not choose to enter into a relationship with doctors but do so because they need care and treatment. Professional boundaries exist to guide doctors to ensure they balance the need for trust with the need for professional distance in their interactions. The GMC’s guidance (2013:53) offers very clear guidance to doctors regarding the limits of their professional role:
You must not use your professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them.
Interactive Exercise: Marlena and Dr.Gallagher
In the following interactive exercise, the GMC presents a patient - doctor relationship over a period of time which demonstrates a potential blurring of the professional boundary:
https://www.gmc-uk.org/gmpinaction/case-studies/marlena/scenario-01/
Undertake the interactive exercise and think about the words and manner you would use for Scenario 3.
The relationship between the doctor and patient is a dynamic one which can change quickly, when maintaining the boundary, context is always very important.
Marlena and Dr. Gallagher met in a night club a year after he cared for her in A&E, when she was a victim of domestic violence and was suffering from depression. Alongside Good Medical Practice (GMC 2013), there is some supplementary guidance ‘Maintaining a professional boundary between you and your patient’, this explores the issues of trust in the doctor-patient relationship and looks at factors affecting patients’ vulnerability. This guidance provides more advice for Dr Gallagher as it states that before pursuing a personal relationship with a former patient you need to consider several factors. The first is the length of time since the professional relationship between you and the patient ended, in Dr Gallagher’s case it was a year ago. The guidance is not specific here about the exact length of time, but it cautions 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 guidance goes onto say that another consideration is the nature of the doctor/patient relationship and the vulnerability of the patient, both when they first met professionally and also at the current time. In this case, Marlena could most certainly be described as vulnerable when she met Dr Gallagher as she was a victim of domestic violence and had depression. Another complicating factor is whether Dr Gallagher was caring for other members of Marlena’s family. If Dr Gallagher was now a GP, he may well have involvement with the rest of her family, which may place him in a complex and challenging position.
So, what about another professional conundrum that we gave at the beginning, is it ever acceptable to hug a patient / relative?
The Medical Defence Union (MDU)writes about just this situation and advises that a lot depends on the context and who initiates the hug (MDU 2018). Hugging another person if they are in distress is a human reaction, shows empathy and it may be appropriate, particularly if the patient initiates it. However, there may also be occasions when a patient goes to hug you as a doctor, and you feel uncomfortable or that it is not appropriate. They suggest that in this case it is important to make it clear to the patient that refusing to hug them is not personal, and perhaps offer a handshake as an alternative.
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Thinking point: What physical contact have you had with patients? A handshake? A hug? How was it initiated? What are the factors that help you work out whether it is appropriate or inappropriate? |
The GMC guidance does not specifically consider this situation, but again offers you principles on which to base your decision making. In fact, GMC guidance is clear in asking you to use your judgement in applying these principles to the many and various situations in which you find yourself as a doctor. This situation could also be described as in the grey area of boundaries that we discussed earlier. The MDU concludes that offering or accepting a hug can be interpreted as blurring these boundaries between showing empathy and being over familiar.
Going back to the principles in Good Medical Practice about the importance of documentation (GMC 2013) this may be a situation where you document what happened and why, including who initiated the hug.
What about the other questions? How much should you tell patients about yourself? We are all aware that in everyday relationships we share information about ourselves and our lives. Evidence shows that sharing personal information helps relationship building and trust, but is it appropriate for a doctor to share this information with a patient? This is called self-disclosure, which has its risks and benefits. These are considered by Lussier and Richard (2007) who suggest that it builds a special bond between doctor and patient. However, conversely this also has the potential to lead to undesirable behaviour.
The risk is that the therapeutic dialogue between a patient and a doctor becomes too focused on the doctor and not the patient, who should be central to this. However, if a patient has a certain condition, for example bunions or a previous hernia operation it can help them greatly to know that the doctor truly appreciates their experience from a personal perspective too and it can add depth to the interaction. Looking at sharing more personal information, such as your loss of a loved one or your own depression is and feels different, though; as a doctor, when thinking about professional boundaries, following your gut feeling is vital. If it feels wrong, it most probably is. GMC guidance does not specifically deal with this issue, but it asks doctors to work in partnership with patients. If you discuss something personal about yourself with a patient, you should ask yourself if this changes the partnership nature of your role with the patient or if it puts more pressure on your patient to act in a certain way.
Another professional boundary concern is ‘How do you care for a patient who repels you? And conversely ‘Is it OK to have a favourite patient?’ We are all individuals and we all have unconscious biases. It is important to be aware of these and understand where they come from in ourselves. Why are we more drawn to certain patients? For example, does the elderly widow who has lived on her own for the last 20 years, remind us of our parents? Does the alcoholic patient remind you of your aunt/uncle? How did their alcoholism affect your family? Consequently, can you see how this patient’s family may have been affected by their alcoholism? Does this make us behave differently with them? If such relationships are causing you concern, the best thing is to access training on equality, diversity and inclusion at your place of employment, this will provide you with a space to explore your own unconscious biases and manage them professionally. The MDU offers further guidance on dealing with challenging patients (MDU 2020). A topical boundary question is – should doctors accept social media requests from patient or ex-patients? This is a question we will refer to in Section 5.