When I kissed the consultantBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e4183 (Published 19 June 2012) Cite this as: BMJ 2012;344:e4183
Relationships among medics can be problematic in a teaching environment
“Really? He’s going out with her?” “But she’s . . .” “I know.”
We’ve all had it—the moment at medical school when you hear that the quiet guy whose name you’ve never known has beaten you in the Top Trumps of intraprofessional dating and has bagged himself a mysterious, glamorous sounding registrar girlfriend, a woman complete with General Medical Council number, BMW 1 series, and the power to award you an A. He’s 22 and she’s 26, but when has an age gap stopped anyone madly in love? Look at Hugh Hefner and Crystal Harris.1 OK, bad example.
More astonishing, though, is the fact that a classmate has deviated from the well trodden healthcare hierarchy that places medical students firmly at the bottom. They have dared to mix way above their intellectual rank and kiss the teacher. Or perhaps even more titillating for the coffee room gossips, the teacher has dared to kiss them.
Medic-medic relationships are to be expected. As students and junior doctors you are cooped up for years with a group of attractive and talented budding medics. As you are deserted by non-medic friends who are sick of your unsociable working hours and tedious medic conversations, your social circle narrows, and it becomes increasingly inevitable that your match is to be found somewhere on your rotation. Unsurprisingly, one study has shown that half of all doctors are married to doctors,2 and I bet that most of them were in the same class, their eyes meeting over some half dissected corpse. That’s how my parents met anyway.
Perhaps as a protest against the predictability of dating the guy who sits three rows in front in lectures, brave junior medics widen their net and scour the doctors’ rooms and theatres to find a more exotic alternative. There’s nothing wrong with going for someone from a different year, but how does their grade or level of training in comparison with yours affect the appropriateness of the relationship?
In a workplace hierarchy there will be a difference in power between individuals. An important factor must be the potential for harm to the more vulnerable party—in this case, most likely the student.
From the beginning of medical school we are told that doctors should never date their patients. Accusations of preying on the vulnerable, abusing a position of trust, and eroding professional integrity are all persuasive reasons against such relationships. Indeed, in the United Kingdom the General Medical Council has extensive guidance on the topic, requiring doctors to “maintain a professional boundary between themselves and their patients.” Although some general guidance exists for staff about relationships in the workplace (box), why do we never hear warnings specifically against student-doctor, student-teacher, or senior-junior doctor relationships?
Jonathan Coe is the director of the Clinic for Boundaries Studies, an organisation that supports the victims of professional boundary violations and educates professionals in improving their approaches to prevention. “When we [patients] go to a doctor, we bring with us a level of vulnerability to the relationship,” says Coe. “Implicitly we are seeking assistance with issues whose solution is outside our knowledge and ability to respond effectively. There is a clear power differential, and it is this that means that senior practitioners need to be careful before entering into any kind of personal involvement.”
Coe argues that the guiding ethical principles that underpin the doctor-patient relationship are also relevant in the context of doctor-student matches. “There is a general ethical responsibility to avoid harm [non-maleficence or beneficence] and to respect autonomy,” he says, “both of which are at risk if an intimate relationship [among doctors and students] is started.”
“There is also a general principle around integrity,” says Coe. “That is that the position of teacher is implicitly about one thing: helping with someone’s learning. If it becomes about another thing then a trust is breached. It is this breach of trust that can be felt as so damaging to people, especially if combined with the kind of idealisation which often goes hand in hand with these extra-pedagogical relationships.”
It could also be confusing for those in the relationships, argues Coe. “Is this person teacher or lover?”
Conflicts of interest
Aside from potential damage to the more vulnerable party, junior-senior relationships can become particularly problematic when the senior member has some responsibility for the junior’s prospects.
Daniel Egan, assistant professor of clinical medicine at Columbia University College of Physicians and Surgeons, argues that the main problem with junior-senior relationships is the conflicts of interest.
“I think with the doctor-student relationship it is obvious,” says Egan. “If there is grading or evaluation as part of the professional relationship, the potential for bias or an unfair evaluation enters the picture. There may be difficulty in separating the professional from personal.”
As well as the student being unfairly assessed, Egan suggests that evaluation of the tutor by the student will also be biased.
For reasons such as these, many US universities now have policies banning relationships between tutors and students. The situation in UK universities is less clear. A request by the Times Educational Supplement under the Freedom of Information Act 2005 showed that 50 of 102 British higher education institutions had no policy requiring tutors to declare relationships with students that might give rise to a conflict of interest.3
These actual or perceived conflicts of interest are the basis of many of the rumours and underhand comments (“An A for a lay” and so on) that accompany student-senior relationships.
Will Amy get an A?
Amy, a fourth year student, is going out with a foundation year 2 doctor who teaches her class. Her university allows relationships between staff and students but requires that they are reported so that the timetables can be arranged to avoid conflict of interest issues. Amy hasn’t reported her relationship.
“I haven’t told them,” she says. “Obviously all of our friends know about ‘us,’ and they’re all totally fine with it. I’ve sorted my timetable myself so I’m never taught by him, and there are no sessions when we’re together. Because of that, I just don’t think the university needs to know.”
But what about the classmates who are taught by him? Aren’t the policies in place for the comfort of classmates as well as for those in the relationship?
“I suppose a few people may feel that their mark is affected by me going out with their teacher,” says Amy, “but they shouldn’t. We obviously talk a bit about people we both know, but I’m confident that he’s professional enough to fairly judge them for himself.”
Managing actual and perceived conflicts of interest is at the heart of the various institutional policies that guide student-teacher relationships. As far as Amy is concerned, she is managing both well on her own.
Junior-senior matches bring trust in the senior doctor into question and can affect colleagues and patients. For something that arises from a fundamentally professional encounter, why is there so little guidance?
“Whilst there may not be any direct reference to these types of relationships,” says Coe, the GMC’s Good Medical Practice could be seen to cover them, as there are requirements to be honest and open and act with integrity, avoid unfair discrimination against patients or colleagues, and work with colleagues in the ways that best serve patients’ interests, all of which are relevant here.
“Developing guidance may be helpful, and it would draw attention to this underexamined area and assist clinicians to make a distinction between the personal and professional,” explains Coe. “Clinicians report an absence of training around these matters.”
For Egan, the matter is simple and the guidance is common sense. “I recognise that the attraction that occurs between two people cannot really be controlled,” he says. “Both parties in these situations are consenting adults, so if I had to provide students with advice, I would just make sure that everyone is fully informed. It is in the best interest of all parties involved to speak with their supervisors and disclose the situation so that everyone is aware.”
NHS staff guidance4
Doctors must be open about the existence of a relationship with another staff member and should take active steps to avoid any suggestion of lack of probity.
Managers should proactively make and record decisions, to avoid or minimise the possibility of perceptions of favouritism or lack of integrity.
If the relationship breaks down, both parties must be courteous and professional to each other at work.
Competing interests: None declared.
From the Student BMJ.