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Professional Boundaries in the Doctor-patient Relationship

Discussion in 'Doctors Cafe' started by Ghada Ali youssef, Jan 7, 2017.

  1. Ghada Ali youssef

    Ghada Ali youssef Golden Member

    Dec 29, 2016
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    In this article Dr Gareth Gillespie of the Medical Protection Society (MPS) is going to share with us his opinion about the importance of maintenance of professional boundaries between doctors and patients.

    The festive season is almost upon us and, for those who celebrate Christmas, it is a time for peace on earth and goodwill to all men. While this goodwill may not be replicated among all your patients, there is nevertheless a question over what to do when these warm intentions breach the professional boundaries that divide doctor and patient.

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    Accepting gifts or engaging patients on social networking sites can, potentially, lead to situations as damaging to your career as embarking on a romantic relationship with a patient. MPS has experience of cases where such seemingly innocent moves have landed a doctor in trouble. HPCSA guidance puts the onus on the doctor to avoid improper relationships with patients, but you should also be aware of how to handle situations where it is the patient pursuing the relationship.

    The human touch

    As a doctor, you are expected to show compassion and empathy when treating patients, and it is undoubtedly a challenge to show this human face without blurring the boundary between professional and personal relationships. The HPCSA is clear in its view; in its Guidelines for Good Practice in the Health Care Professions it says: “Avoid improper relationships with their patients, their patients’ friends or their patients’ family members (for example, sexual relationships or exploitative financial arrangements).”1 Elsewhere in the guidance, the HPCSA reminds doctors: “Be mindful that they are in a position of power over their patients and avoid abusing their position.”2

    Knowing how to maintain this boundary depends largely on a doctor’s self-awareness and their ability to judge the particular situation. A reassuring hug, for example, depends largely on the pre-existing familiarity between doctor and patient. Your best protection is to know yourself: become adept at identifying and monitoring your feelings towards your patients (whether these are negative or positive):

    • Be aware of how you portray yourself to patients.

    • Do you feel uncomfortable with a patient? If so, try to identify the cause – is it something they said, or did, or was it their body language?

    • Do you feel a special rapport or attraction to a particular patient? If so, seek advice from a colleague and deal with the situation before it escalates, either by establishing clear professional boundaries and sticking to them, or by referring the patient’s care to another doctor.

    The way in which patients interpret your behaviour can give them the wrong idea, and they are likely to report you to the HPCSA if there is the slightest suspicion that your intentions are unsavoury. The doctor-patient relationship can be a fragile one, as it is built on the trust that patients place in you – this is demonstrated by their willingness to shed their privacy in the company of what otherwise would be a complete stranger. Unfortunately, even the most well-meaning doctor can fall foul of a patient’s misinterpretations, so here are some examples of behaviours that can lead to this:

    • Using the patient’s first name

    • Lingering eye contact

    • Using direct talk

    • Physical contact or intimate personal space.

    Whether patients are responding to their misinterpretation of your actions, or whether you are genuinely in their affections, such approaches can take a number of different forms. Flirting or sexual innuendo, social invitations – even such seemingly innocuous requests such as a coffee or a trip to the cinema – and gift-giving are examples of where a patient is making an inappropriate approach. Politely decline, expressing your gratitude for the gesture, and gently explain that the professional nature of your relationship forbids you from accepting. Small gifts are usually harmless but can potentially lead to more substantial gift-giving; in the case of a relatively small Christmas gift, you could ask if the patient minds you sharing it with the rest of your team. Large, expensive gifts should be declined.

    Dr Graham Howarth, MPS head of Medical Services (Africa), says: “It can be difficult to draw the boundaries between being friendly and compassionate towards your patients, and their mistaking this for something more. Some patients may use their perceived friendship with you to gain advantage, or others may be genuinely attracted to you. Remember, though, that if such approaches are unwanted and become sustained, then this is harassment and you should take it seriously. Discuss it with colleagues and, if possible, arrange for care of the patient to be transferred to one of them.”


    Worlds apart

    Being aware of professional boundaries also extends to doctors’ use of social media. It is now practically ever-present in people’s lives, and doctors should be particularly aware of the risks. There have been numerous examples in the media about doctors revealing confidential patient information on blogs, Facebook, Twitter and other forums, while doctors who fail to restrict access to their private lives – and the particularly personal photographs or videos that are a common feature for some – risk damaging their professional image.

    Social media is a new arena within which doctors must tread carefully. Friend requests on Facebook that are received from patients should be rejected, for the same reasons described earlier in this article – it is another breach of boundaries and blurs what should be a professional relationship. Consider whether you are comfortable with your patients viewing photos and videos of you in a relaxed or social context. It is unlikely that your patients would be able to view you in the same trustworthy, dependable light as before.

    Case study

    Dr E was a young GP who had been working at his current surgery for two years. The surgery was owned by two well-respected partners who had practised in the small town for more than 30 years.

    Dr E, who was married, occasionally stayed late in the surgery, where he was usually joined by clerical support worker Miss D as the only other member of staff in the building. Miss D was also a patient at the surgery and had consulted Dr E on at least a couple of occasions.

    Around six months after Dr E began working late, his wife discovered text messages from Miss D on his mobile phone. They were of a flirtatious and sexual nature, and even though Dr E had not responded, his wife accused him of being unfaithful and threatened to tell the partners at his practice.

    Embarrassed, Dr E reported the issue to the partners who were concerned that he had not informed them previously and had done nothing to manage the situation, leaving the practice vulnerable to a complaint by Miss D as an employee and a patient. Dr E eventually resigned.


    1. HPCSA, Guidelines for Good Practice in the Health Care Professions, para 5.2.4 (2008)

    2. Ibid, para 5.1.3


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