Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Warning to doctors alone: a matter of convenience?
- Dr. Rajesh Chauhan, Dr. Akhilesh Kumar Singh, Dr. Parul Chauhan, Shruti Chauhan. (5 December 2006)
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Does the specialty make a difference? And what about colleagues who are patients?
- William H Konarzewski (6 December 2006)
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Dating Patients
- Chris Jones (6 December 2006)
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Already Guilty?
- Gerald Freshwater (6 December 2006)
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A common solecism
- Neville W Goodman (13 December 2006)
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Doctor-patient relationship without sex
- Mamdouh EL-Adl (18 December 2006)
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Boundary Violations ; Importance of Formal Training
- Dr DUMINDU WITHARANA, Dr. AMUL PATEL, SHO in Psychiatry (19 December 2006)
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Dr. Rajesh Chauhan, Consultant Family Medicine, Hospital & Health Administration, & Communicable Diseases 309/9 A.V. Parishad, Sikandra, AGRA -282007. INDIA., Dr. Akhilesh Kumar Singh, Dr. Parul Chauhan, Shruti Chauhan.
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Dear Editor, Moralities, probity, attitudes, and trends are changing at a swift pace. Unlike the yesteryears when the news, the fashion, and the trends took time to travel, communication is much faster nowadays and therefore trends are being assimilated at a faster pace than ever before. It should therefore be a matter of great pride that when everything else in this world has changed or is falling apart, only the Hippocrates’ oath of the pre-Biblical vintage has stood the test of time [1]. It still keeps governing the actions of the physicians all around the world, notwithstanding the overall changes within the society where so many things are happening that can equally affect the Doctors, since they are also a part of the same society. Howsoever astute and stoic doctors may be, due to the influence of their training, character building, moral leanings and peer influence, some may still get influenced by the changes within the rest of the society [2,3,4]. There are ample checks, means and modalities within the medical profession which need to be strengthened and implemented energetically [5]. We honour this oath and stand by it, and certainly almost everyone from the medical fraternity would voice similar feelings. One has to use both hands to clap. However, the issue of the warning by the society seems to generate the idea that it remains the fault of the doctor and only of the doctor and therefore is to be objected [6,7,8]. Are we not naïve in totally de-linking the role of a patient and the society? Must the society conveniently overlook whatever is happening around and what about the scores of statistics generated worldwide on the issues of liaisons outside marriage, pre-marriage, and of the divorced and widowed in the society? What about the HIV pandemic? Has someone ever thought of assessing this problem while correlating it with the highest ratings that the doctors always score from the general public in such surveys when it comes to define the best of the choices available? Therefore, doesn’t this warning being issued to the doctors amounts to a matter of convenience for the society, which lacks the will and the wherewithal to rein in their very own, but rather finds it easier and most convenient to flog the doctors, right since the pre-biblical Hippocrates era. Are we waiting for a messiah to lay down a code of conduct for the society as well? Warm regards. References: 1. Chauhan R. Changing ethics: Where to start? Can. Med. Assoc. J., Oct 2006; 175: 922 ; doi:10.1503/cmaj.1060117 2. Campbell ML: The oath: An investigation of the injunction prohibiting physician-patient sexual relations. Perspect Biol Med 1989; 32:300-308 3. Searight HR, Campbell DC. Physician-patient sexual contact: ethical and legal issues and clinical guidelines. J Fam Pract 1993; 36 (6): 647-653. 4. Gartell NK, Milliken N, Goodson WH, Thiemann S, Lo B. Physician- patient sexual contact. Prevalence and problems. West J Med 1992; 157 (2): 139-143. 5. Chauhan R. Where are we failing: time to introspect. Ann Intern Med 02 Nov 2005. http://www.annals.org/cgi/eletters/143/4/305#2315, 2 Nov 2005 6. Sheather J. Sexual relationships between doctors and former patients. BMJ 2006; 333 (7579): 1132 - 1132. 7. Eaton L. Doctors are warned against sex with former patients. BMJ 2006; 333(7574):876. 8. Kamerow D. US Highlights. BMJ 2006;333 (2 December), doi:10.1136/bmj.39050.451759.3A Competing interests: None declared |
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William H Konarzewski, Consultant Anaesthetist Colchester General Hospital, Colchester, Essex CO4 5JL
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Dear Editor, I think that any GMC guidance on this delicate subject should make reference to the doctor's specialty and the nature of his/her relationship with the patient. Whilst the relationship between a male general practitioner and a distressed young female ought, quite properly, to preclude an intimate relationship, there are numerous other situations where the relationship is far less fraught, particularly when the patient is also a colleague. If for the sake or argument, one doctor examines another doctor's ears and prescribes treatment, should that preclude a relationship? Again, what is the situation if doctors meet, in a social context, patients on whom they have carried out a minor procedure in the past - this might apply to surgeons, anaesthetists and radiologists. Are relationships taboo in these circumstances? Obviously vulnerable patients must be protected, but common sense must prevail. Yours sincerely,
Competing interests: None declared |
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Chris Jones, Senior Lecturer Faculty of Health, Aintree Complex, Edge Hill University, Liverpool L9 7NL
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I am often struck by the difference in attitude taken to doctors who form relationships with patients and nurses who do the same. If the classic instance of a doctor-patient relationship is a male doctor and a female patient, the classic instance of a nurse-patient relationship is that of a female nurse with a male patient. The former attracts censure and possible disqualification. The latter attracts warm hearted details and best wishes published in the local press, particularly when there are wedding bells. What can account for this difference? I have often felt that the power differential lies not so much between a male doctor and a competent and mature female patient. The power differential is between doctors and other men, who are conscious of the advantage a white coat brings in the mating ritual. I wonder how many cases are brought before the GMC by disgruntled husbands. Competing interests: None declared |
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Gerald Freshwater, Occupational Physician Shetland Medical Services, Lerwick, ZE1 0EL
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After reading the leader (BMJ 2006;333:1132 (2 December),) about sex with former patients, I was seriously troubled. In 1971, I performed a minor surgical procedure on a young nurse. The following year we began a relationship which was not platonic. Now I find it to have been inappropriate. Should I own up to the GMC? Shall I be struck off? What can I tell the children when it hits the tabloid press? Must I now divorce the victim of this heinous abuse of my professional position? Before rushing to confess, I read the actual advice from the GMC. Much to my surprise, given the recent performance of that august body, it was extremely reasonable. Of course, the concept of discussion with a colleague or the Council before embarking on a sexual relationship is a waste of time: anyone who is prepared so to do has already thought through the possibilities of exploitation. Those who are exploiters will not feel a discussion with anyone to be appropriate. Otherwise the guidance is good; think carefully before doing something that will affect the lives of all parties involved, which ought to apply in every aspect of doctor/patient relations. The leader presents a more alarmist view, apparently backed up by a very brief quotation from Graeme Catto, implying that any relationship following that of doctor/patient will be viewed as inappropriate, unless the circumstances are exceptional. Whilst Julian Sheather calls for balance, there is no reason why this balance cannot be reached without significant breach of the published guidance (except for the nonsense bit at the end). Happily, the lay press do not seem to have latched onto this subject, but it is easy to see headlines of the “Doctors wait to abuse ex-patients” variety appearing as a result of it. Perhaps I have misread the leader, but it was more alarming than the published guidance deserves, which is not ideal in such an authoritative organ of the profession. Gerald Freshwater Competing interests: Subject to reigistration with GMC |
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Neville W Goodman, Consultant Anaesthetist Southmead Hospital, Bristol, BS10 5NB
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"Should doctors in such relationships, as the guidance infers, discuss their relationships with a member of the GMC standards and ethics team?" No: the guidance implies; we doctors infer. Competing interests: None declared |
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Mamdouh EL-Adl, Psychiatrist, MBChB, MSc, MRCPsych Princess Marina Hospital, Upton, Northampton, NN5 6UH
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Editor Sheather’s editorial in BMJ of 2.12.2006 addresses a very sensitive ethical matter within a very special relationship between doctors and patients. Sexual misconduct usually begins with minor boundary violation[1]. Boundary violation or crossings are injurious to patients [2]. No doubt this could be harmful to doctors as well. A survey of medical students in Scotland revealed that 4:10 believed that sexual relationship with patient is OK![3]. In new Guidance, the General Medical Council (GMC) has warned doctors to think long and hard before embarking on a sexual relationship with a former patient[4]. In my opinion, this new GMC guidance may raise the awareness of many doctors and at the same time is likely to bring more questions than answers. Some of these questions have been already raised in Sheather’s editorial & the rapid responses: (1)Nature of the contact (once in the casualty or prolonged & recurrent). (2)Does specialty matter?. (3)If former patient was a fellow doctor. (4)Are patients now equal partners in the doctor–patient relationship? (5)Have doctors become more vulnerable? (6)How about patient’s responsibility? (7)Will GMC view any relationship between a doctor and former patient as inappropriate? (8)How about if the doctor/former patient is un/married?, and yet many more questions to be raised. (9)Does the society expect the same from other professionals? If not, why treat doctors differently? No doubt various societies pay great respect to the medical profession and therefore have high expectations from the doctors. For various reasons concerns have been expressed for warning the doctor about having sex with a former patient. Dr Chauhan expressed his concern: Warning doctors seems to generate the idea that it remains the doctor’s fault?[5]. This is an important point: sending the wrong message is likely to undermine public confidence in their doctors. However, doctors definitely have more role to play in keeping boundaries. In my opinion doctor-patient relationship is a very special & very important relationship that needs protection and all parties have to work together to achieve this. I feel we have to do this for the best interest of patients, doctors, the medical profession and the society. Dr Mamdouh EL-Adl References: 1. Gutheil TG & Gabbard GO : The concept of boundaries in clinical practice: theoretical and risk-management dimensions. Am J Psychiatry, 1993,150:188-196 2. Hall, K: Sexualisation of the doctor-patient relationship: is it ever ethically permissible? Family Practice, 2001,18:511-515 3. Goldie J, Schwartz L & Morrison J: Sex and the surgery: Students’ attitudes and potential behaviour as they pass through a modern medical curriculum. Journal of Med Ethics 2004; 30:480-486 4. Sheather J: Sexual relationships between doctors and former patients. BMJ 2006;333(7579):1132–1132. 5. Chauhan R., Singh A. K., Chauhan P. & Chauhan S.: Warning doctors alone: a matter of convenience? BMJ.com/cgi/eletters/333/7579/1132, accessed on 16.12.2006 Competing interests: None declared |
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Dr DUMINDU WITHARANA, SHO in Psychiatry worcestershire mental health partnership nhs trust, Dr. AMUL PATEL, SHO in Psychiatry
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Julian Sheather’s article on “Sexual relationships between doctors and former patients” (1) was very interesting and generated lot of responses in a short period of time. Majority of responders showed anxiety towards GMC guidance and it’s implication on the medical profession as a whole. Some appear to have perceived this as a victimization of the profession which has been holding to its values for thousands of years. As a part of our psychiatric training, we got opportunities in our academic programmes to make presentations on boundary violations, which were very interactive and generated lot of discussion. Strikingly, but not surprisingly, we came to know that most of us had not had any formal training on this subject either during undergraduate or postgraduate training, although fortunately knowingly or unknowingly we were able to incorporate the concept in our professional work. Although it is commendable for majority of doctors to maintain professional boundaries with the patients, lack of information and formal training on the subject can be quite dangerous for minority of the patients. Also, the GMC expecting doctors to act according to stricter guidelines without a proper formal training appears unreasonable. Providing a formal training to doctors will not only ease the anxiety and reassure vast majority of doctors who are doing a great service without violating boundaries but also decrease the minority of incidences of boundary violations occurring at present(2). References 1. Sheather J.(2006) Sexual relationships between doctors and former patients. BMJ, 333 (7579): 1132 - 1132. 2. Sarkar,S.P (2004) Boundary violation and sexual exploitation in psychiatry and psychotherapy : a review. Advances in Psychiatric Treatment,10, 312-320 Competing interests: None declared |
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