Crossing boundaries: dealing with amorous advances by doctors and patientsBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5368 (Published 18 November 2015) Cite this as: BMJ 2015;351:h5368
- Marika Davies, medicolegal adviser, Medical Protection
Marika Davies considers the risks of inappropriate relationships with patients and looks at how to deal with unwanted advances by patients
Professional boundaries are an essential part of the doctor-patient relationship, but they are sometimes crossed by both doctors and patients.
In 2013-14 the General Medical Council (GMC) investigated 93 complaints against 90 doctors who were alleged to have had an inappropriate relationship or made inappropriate advances towards a patient. The figures, which BMJ Careers obtained through a freedom of information request to the GMC, showed that the majority (91%) of these complaints concerned male doctors.
Doctors who enter into a personal relationship with a patient put their registration at risk and can also expect a high level of media interest should the matter become public. But why do the GMC and the media take such an interest in a relationship between two apparently consenting adults?
The answer lies in the unique nature of the doctor-patient relationship and the power imbalance in that relationship. Patients may be vulnerable—for example, those who have mental health issues or who see doctors at difficult times in their lives, such as during illness or bereavement. Also, during a medical consultation, patients confide sensitive and personal information to someone they may have only just met, and doctors can ask a complete stranger to undress so that they may examine them.
Trust is therefore essential: the GMC describes it as the foundation of the doctor-patient partnership. “Patients should be able to trust that their doctor will behave professionally towards them during consultations and not see them as a potential sexual partner,” it says.
A key part of maintaining that trust is the professional boundary that exists between doctors and their patients. The Royal College of Psychiatrists says that boundaries are there to keep both doctor and patient safe, but these boundaries may be crossed or violated.1 Crossing the professional boundary—for example, a hug after a bereavement—may be beneficial to a patient. But even apparently minor actions can be risky: the development of a sexual relationship between a doctor and their patient often occurs after a series of boundary crossings.
A boundary violation, such as a sexual relationship with a patient, is defined as always being harmful or having the potential to cause harm.1 This is because boundary violations can compromise the quality of patient care and undermine both the trust of the patient in their doctor and the trust of the public in the medical profession.
Both doctors and patients may be responsible for taking the first steps across the professional boundary. Recognising early warning signs and dealing appropriately with situations or feelings is key to preventing the situation from escalating.
The amorous patient
The types of patients who pursue their doctor range from those with inappropriate feelings that may be secondary to loneliness and poor relationships, to those who are delusional and may have an underlying psychiatric illness.2 The response to an advance from a patient should be appropriate and proportionate to their actions.
Some patients express their feelings by using non-verbal communication—for example, by giving inappropriate gifts or cards. They may act in ways that increase contact with their doctor, such as requesting the last appointment of the day or not complying with advice.
Doctors who recognise this behaviour should take care to avoid any action that could be seen to encourage the patient. They should adopt a more formal and professional manner and make sure they focus on medical issues during the consultation. Doctors should politely decline to accept cards or gifts and should discourage an inappropriate frequency of consultations, perhaps by suggesting the patient sees a colleague for a second opinion.
A more challenging example is the patient who behaves in an obviously seductive manner and may declare their feelings for the doctor. The doctor may need to take more direct action, and the patient should be firmly reminded of the importance of professional boundaries.
GMC advice to doctors whose patient has pursued a sexual or improper emotional relationship is that they “should treat them politely and considerately and try to re-establish a professional boundary.”3 The GMC acknowledges that it may be necessary to end the professional relationship if trust has broken down. These measures may not be effective for all patients, and a small number of patients will continue to pursue the doctor in the hope of a relationship, perhaps even believing that the doctor reciprocates their feelings. A psychiatry opinion should be considered in these cases.
In the event of an advance by a patient, doctors should inform their senior or a colleague. They should document these discussions as well as the contacts they have had with the patient, and they should keep a log of all messages the patient has sent, including emails and text messages. It may be necessary to transfer the patient’s care to someone else in the team, and doctors should seek advice from their defence organisation.
Doctors behaving badly
In situations where a patient behaves amorously, doctors also need to be aware of their own feelings. Matthew Large, a psychiatrist in Sydney, says that doctors may feel flattered, but they should be aware that it is not necessarily a sign of their own personal qualities or attractiveness. “It may be symptomatic of the patient’s unsatisfactory life, personality disorder, or even illness,” he says.2
Doctors are more likely to cross or violate boundaries if they are having personal or professional difficulties. Stress and illness are also sometimes reasons why doctors have acted inappropriately.
The Royal College of Psychiatrists says it is important to tackle stress and burnout as early as possible and to communicate with colleagues and mentors about this.1 MDA National, a medical defence organisation in Australia, has compiled a checklist for doctors to identify any risky behaviour with respect to boundaries (box 1).
A relationship develops
Occasionally advances from either side are reciprocated and an intimate relationship may develop between a doctor and patient. The GMC takes a dim view of relationships with current patients. Its advice to doctors says that “you must not pursue a sexual or improper emotional relationship with a current patient.” Advising the patient to seek care elsewhere is not a solution. The GMC’s guidance goes on to say that doctors “must not end a professional relationship with a patient solely to pursue a personal relationship with them.”3
Personal relationships with former patients may also be inappropriate, depending on a number of factors, such as whether the doctor will be caring for other members of the patient’s family. GMC guidance does not specify a length of time after which it would be acceptable to begin a relationship with a former patient. However, it points out 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 duration of the professional relationship may also be relevant. “For example, a relationship with a former patient you treated over a number of years is more likely to be inappropriate than a relationship with a patient with whom you had a single consultation,” the guidance says.
The vulnerability of a patient is also highly relevant, and the more vulnerable a patient is the more likely it is that having a relationship with them would be an abuse of power and the position of a doctor. “Pursuing a relationship with a former patient is more likely to be (or be seen to be) an abuse of your position if you are a psychiatrist or paediatrician,” says the guidance.
The American Medical Association adopts a similar stance on relationships with former patients, which it warns may be unduly influenced by the previous doctor-patient relationship. “Sexual or romantic relationships with former patients are unethical if the [doctor] uses or exploits trust, knowledge, emotions, or influence derived from the previous professional relationship,” it says.4
Katherine Hall, a general practitioner in New Zealand, argues that relationships between doctors and their former patients are almost always unethical.5 One of the reasons for this, she says, is the persistence of the unequal power distribution in the original doctor-patient relationship, which has implications for the patient’s autonomy and ability to consent. Only in very particular circumstances could such relationships be ethically permissible, she says.
Box 1: Identifying risky boundary behaviour6
● Is what I am doing part of accepted medical practice?
● Does what I am doing fit into any of the recognised high risk situations that I have learnt about?
● Is what I am doing solely in the interest of the patient?
● Is what I am doing self serving?
● Is what I am doing exploiting the patient for my benefit?
● Is what I am doing gratuitous (not what the patient has asked for)?
● Is what I am doing secretive or covert? Would I be happy to share it with my spouse, partner, or colleagues?
● Am I revealing too much about myself or my family?
● Is what I am doing causing me stress, worry, or guilt?
● Has someone already commented on my behaviour or suggested I stop?
Box 2: Case studies
Dr A, a trainee in the emergency department, treated a female patient for a fractured wrist. He made a note of her phone number from the medical records and later contacted her by text message asking if she would like to meet for a drink. She did not reply but he continued to send her messages telling her he found her very attractive. She eventually complained to the hospital trust after a Valentine’s Day message from the doctor which was sexually explicit. The doctor was referred to the GMC, which issued him with a warning which remained on his record for five years.
Dr B, a GP, contacted Medical Protection with concerns that a GP colleague was making an unnecessary number of home visits to a recently bereaved patient. There was no documentation of the visits in the medical records and there was no apparent clinical indication for them. On the advice of Medical Protection she discussed her concerns about patient safety with the other GP partners and an investigation took place. The senior partner questioned the patient and discovered that she had been in an intimate relationship with the GP for some time. The practice reported the matter to the local area team and the GMC, where the GP was suspended for six months.
Dr C, a rheumatologist, saw a patient for several years with a chronic condition. The patient often brought in small gifts and cards as an expression of his thanks. He then started attending more frequently and sent the doctor a friend request on Facebook, which she declined. At Christmas he sent her a gift of lingerie, at which point the doctor contacted Medical Protection for assistance. Medical Protection advised her to return the gift and helped to write a firm letter to the patient to remind him of the importance of the professional boundary in the doctor-patient relationship. The patient was also informed that his care would be transferred to a colleague.
Dr D, a general practitioner, had a six month affair with a patient. When Dr D ended the relationship the patient made a complaint to the GMC, alleging that she had been emotionally unstable at the time of the affair and that the doctor had taken advantage of this. At a public hearing the fitness to practise panel heard evidence about the relationship, including the intimate text messages sent by the doctor to the patient and the patient’s account of their illicit liaisons in hotel rooms. The panel suspended Dr D from the medical register for 12 months, and details of the case were published widely in the media.
Competing interests: I have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.