Ever tempted to cross the line, or have you crossed it unintentionally? Anahita Kirkpatrick from the Medical Defence Union starts off our series on medicolegal matters, by focusing on patients' relationships with doctors or medical students

The thought of a patient chatting you up may seem like a harmless boost to your ego, but when you become a doctor, and even occasionally as a student, amorous advances from patients could endanger your career. Everyone thinks, "It won't happen to me," but consider the following scenarios involving qualified doctors and students and think again. Start as you mean to go on by taking action early to discourage advances from patients that cross the line.

Scenario one

If only she had been a little more positive. If only she had tackled the situation when she had had that first uneasy flutter in the pit of her stomach. If only she had done that she would not be standing here today staring at the carpet in the main chamber of the General Medical Council.

How it started

A newly qualified general practitioner was anxious to make a good impression in her first job in a small county town. She was determined to take time with all her patients, see them as whole people not just symptoms.

One patient in his late 50s had a long history of panic attacks and depression after his wife died. Several consultations turned into long talks about his loss and his life. He sent the general practitioner some flowers with a nice message thanking her for taking the time and being so sensitive. She was flattered and touched, but she thought no more of it.

The end of the beginning

More flowers and then small gifts arrived. It was then the general practitioner had an uneasy feeling but decided that if she ignored it, the patient would get the message and stop. A week later the patient called for a "quick chat about drugs," which rapidly turned to him asking questions about her hobbies, relationships, and where she lived. On a couple of occasions the general practitioner was shocked to find him loitering in the surgery car park "just to say hello."

The beginning of the end

The general practitioner was working at the local out of hours cooperative when the patient called at 1 am asking for a home visit. He described feeling breathless, sweaty, and nauseous. She was concerned that he may be faking a panic attack to get her alone, so she told him that a home visit would not be necessary and suggested he used some of the anxiety reduction techniques they had previously discussed instead.

The patient eventually staggered round to a neighbour's house who immediately called an ambulance. The patient was having a myocardial infarction and later made a complaint to the GMC.

Comment

This case illustrates how a patient's unwanted attentions can get out of hand, undermining the doctor-patient relationship with potentially disastrous consequences for both doctor and patient. Involving colleagues and taking action to nip the advances in the bud at an early stage are a must.

Polite but firm

Once the patient started to send a stream of gifts, it would have been advisable for the doctor to have told him gently but firmly, perhaps in the presence of a colleague, "Thanks very much for showing your appreciation, but sending gifts is not appropriate." The doctor or her colleague could have then followed up the meeting with a letter recapping on what was said. In most circumstances, explaining to a patient that their actions have overstepped the acceptable boundaries of the doctor-patient relationship will be enough to stop their behaviour. In the rare cases where this action does not work, the next stage may be to consider telling a patient that they will have to see another general practitioner in the practice in future.

Forward to your defence organisation

Sometimes patients make amorous advances to their doctor in a stream of letters. In these circumstances, doctors may decide to explain to the patient that if the patient does not stop sending them, any correspondence received will be sent, unopened, to their medical defence organisation. This is often successful. On the rare occasions when it is not, the organisation's medicolegal adviser can write to the patient on the doctor's behalf, again asking them to desist from writing.

Off the list

If the doctor-patient relationship has irretrievably broken down, general practitioners sometimes find it necessary to end their professional relationship with the patient by removing them from their list. The GMC advises that "you must be satisfied that your decision is fair... you must be prepared to justify your decision if called on to do so... You should inform the patient, orally or in writing, why you have decided to end the professional relationship."¹ General practitioners are advised to make a note in the medical records.

Follow your instincts

This case illustrates that it is all too easy to dismiss a patient's attentions as harmless, but, as a general rule, in situations such as this it is important to follow your instincts. If you have any concerns that a patient's behaviour is crossing the line of the normal doctor-patient relationship, discuss it with colleagues. It is also advisable to contact your medical defence organisation as soon as possible, keep a log of all incidents, and retain originals of all letters and gifts.

What about dementia?

But what about the situation where an elderly patient, showing early signs of dementia, is the one making advances and may not be able to understand why this is inappropriate behaviour? In one case, an elderly woman was showering a male senior house officer with love letters, cards, and little gifts. She was persistent and even her family noticed how much attention she paid to the doctor when they came to visit her on the ward. She had been on the ward for a number of weeks and was showing signs of early stage dementia.

In these circumstances, the inappropriate amorous behaviour is likely to have been a manifestation of the woman's mild dementia. It is important to make a note of this in the medical records. Although the symptoms may have been a little embarrassing and slightly distracting for the doctor, it may be inappropriate and unethical to stop treating her. As she was unwell, it was important that she received appropriate treatment. If her relatives had expressed concerns about the change in her behaviour, it may also have been appropriate to inform them (with her consent, if she has capacity to consent) of the diagnosis and intended treatment, in her best interest. Again it is vital that the doctor keeps a clear, concurrent note of all the incidents, working diagnosis and referral. And that he keeps his consultant and the rest of the team aware of any concerns of this nature.

Scenario two

There are occasions where mutual attraction can create problems. An unattached male student on rotation on a surgical ward got to know a patient who had been on the ward for a few days post operatively. They got on really well, so when the patient asked him out on a date as she was being discharged, the student accepted. Later that evening, he had second thoughts and rang his medical defence organisation to ask if it was wrong to go on the date as it was likely the patient would have to return to the ward in an outpatient capacity.

Comment

The student was advised that, although the GMC does not have direct jurisdiction over medical students, it expects the same standards of behaviour from medical students as it does from doctors. GMC guidance states that, "You must not allow your personal relationships to undermine the trust which patients place in you. In particular, 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."¹

In addition the GMC's education committee has certain powers and responsibilities concerning medical education and has stated that students whose conduct may lead them to become a risk to patients should not be allowed to graduate with a degree that would allow them to register with the GMC and practise as a doctor.²

It is always wise to keep personal and professional relationships separate. When an emotional relationship starts, it is vital that your professional relationship has already formally ended.

Remember

Don't let amorous advances ruin your career:

• Keep strict boundaries with your patients, and act quickly if they are crossed
• Keep a log of contacts
• Keep alert
Keep medical information confidential and disclose only the minimum necessary if you report your patient to the police
• Keep your medical defence organisation and senior colleagues informed of all developments, and take appropriate advice

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