With 58% of doctors now suffering from some form of anxiety or depression – and 46% saying their condition has worsened since last March – our final serialisation of a new book edited by Dr Clare Gerada looks at professional and unprofessional behaviour.
There are now over 30 different sets of guidance for doctors to adhere to in areas relating to clinical, managerial, leadership, medico-legal, research, communication and other areas of our daily professional and even personal lives.
Around 8,000 doctors each year are referred to the GMC and about 200 receive a serious sanction, most commonly suspension, and between 60 and 80 doctors have their licence to practise removed.
Because human behaviour itself is complex, it is hardly surprising that the ways in which it can become deviant from normal mores are so diverse. Of the 119 cases in 2015 that resulted in suspension or erasure, 103 cases related to transgressions involving the doctor’s professional life – most often related to dishonesty, clinical issues or inappropriate relationship with patients – and 16 cases that involved their personal life – drink driving, sexual issues.
Dishonesty and inappropriate sexual relationships made up nearly one-third receiving these sanctions.
Strict professional codes of conduct and public expectations means that the vast majority of doctors follow the rules, honour the trust given to them by virtue of their status and never break the law for their entire career.
However, occasionally, they do transgress and fall short of these standards, some so seriously that they receive a criminal charge and, on rare occasions, a custodial sentence.
Criminal sanctions against doctors are rare. GMC data for 2005-2019 show just over 2,000 doctors in the UK had criminal records – against more than 200,000 on the register.
More than 50% of crimes were for vehicle-related offences such as dangerous driving (speeding, drink- or drug-driving) and motoring offences (driving without insurance or tax).
While it is only speculation, it is likely that many of these are related to alcohol and drug use; this means for treatable mental health problems if the individual had sought help before the criminal incident.
Hopefully, with more accessible, confidential treatment services, doctors in whom health problems have been the underlying issue will come forward for treatment instead of risking their career by suffering in silence.
Other offences occurring much less often involve forgery, fraud, possessing indecent images of children and sexual offences.
Impact on career
Doctors are surprised that an offence committed quite unrelated to work, such as being found guilty of offences against health and safety regulations, can impact on their career. Most regulators expect that doctors’ conduct is of a certain standard, even if they are not at work.
The UK regulator says ‘you must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession’. Any conviction or caution received anywhere in the world needs to be disclosed and doctors must follow the GMC guidance about this.
A criminal conviction does not automatically disbar a doctor from working, though the more serious crimes such as possession of indecent images of children and sexual offences will almost always lead to erasure.
This seems reasonable given public confidence has been breached when a doctor transgresses so seriously. Also, the most robust predictor of future serious offence – such as violence or sexual assault – is a history of past offence.
For less serious crimes, the chances of being able to work are mixed. Many, but not all, minor criminal convictions give reason to doubt a person’s honesty, which is a vital requirement expected from a doctor.
Cheating in exams is one of the most powerful predictors of future dishonest behaviour. Some offences, however, such as using illegal drugs or motoring offences, do not necessarily imply that a person is dishonest, though they suggest the offenders are willing to engage in behaviour that is illegal and harmful to themselves or others.
Clearly, such offences raise serious questions about possible risks to patients, the possibility of more serious crimes being committed or other unprofessional behaviours.
All these issues are taken into account by a regulator and a proportionate balance made on an individual case-by-case basis.
Most cases brought before a medical tribunal concern probity, fraud and dishonesty, and they tend to lead to the harshest of sanctions. Acting with honesty and integrity is a fundamental tenet of the medical profession.
I have looked at the determinations from the Medical Practitioners Tribunal Service and devised a taxonomy that describes what I suspect was the ‘frame of mind’ the doctor was in when they crossed their professional boundary.
1 ‘It was only a little lie’. Dishonesty, fraud, probity
This includes doctors who commit what they might consider to be small deceits, maybe in a genuinely perceived belief that what they are doing is ‘almost true’ and no harm will be done.
They might even believe that it is justifiable, given how busy they are, to take a short cut to obtaining the necessary paperwork or doing the required training.
They might also feel no one will find out and no harm will be done by their ‘little lie’. But it will be found out and harm will be done. The following are examples under this category.
Dishonesty about claiming sick pay while working. A common error is where a doctor regularly works across two sites, maybe a substantive job with the NHS
but also a small amount of self-employed private work elsewhere.
If signed off as unwell and receiving sick pay, it is important to stop all work, including teaching, training, academic, medico- legal, private, media and so on, unless agreement has formally been agreed from the employer issuing the sick pay.
Dishonesty about having done training. A senior doctor amended and uploaded an Advanced Life Support course certificate, adding it to his training portfolio.
Despite a relatively light sanction, he had to still go through 18 months of investigation and shame. His name and what he did will appear on the website for years, and he will have to disclose this misdemeanour whenever he applies for a new job. This is a high price to pay for not doing half a day’s training.
Dishonesty about references. These are not minor errors – which we are all guilty of – but major falsehoods, such as claiming to have obtained degrees. These cases tend to result in harsh sanctions.
As part of a planned move overseas, a doctor submitted two false references with his application. His actions involved the manufacturing of references from start to finish, including false letterhead, false representations, fake personalities from human resources and fake signatures.
He was erased from the medical register, a high price to pay for wanting to speed up an administrative process.
This doctor could easily have obtained the necessary references; there were no reasons why they would not have been provided. Instead, in his haste to emigrate, he forged them and lost his livelihood.
2What harm can it do?
There are many examples of doctors who fall foul of their professional code or even commit an overt crime by trying to help members of their families or friends.
A doctor wrote prescriptions for patients whose names he took from the hospital computer database and took the prescriptions to the hospital pharmacist who noticed discrepancies in the prescription.
He admitted that he wrote the prescriptions for a friend who lived overseas and was erased from the medical register. It is unusual to get such a harsh sanction, but it shows the risk.
3‘I only wanted to be friendly’. Boundary violations
Given the changing nature of medicine, with less formal, more collaborative working and with fuzzy boundaries created by social media, it is becoming harder to maintain clear professional and personal borders between patient and doctor.
Boundary issues involve departures from usual professional practice and can be thought of as being along a spectrum, from ‘crossings’ to ‘violations’.
These are unethical and unprofessional because they exploit the doctor-patient relationship, undermine the trust patients and the community have in us and can cause psychological harm to patients, compromising their ongoing medical care.
The most serious of all boundary violations are those involving sexual contraventions. These cover a range of behaviours including inappropriate contact with staff, colleagues or in unequal relationships, such as with medical students and patients.
Position of trust
Doctors are powerful authoritative figures and in exploiting patients for their own gratification, transgress a position of trust, which can have a similar effect as a parent abusing a child.
It is difficult to know how many doctors have crossed a sexual boundary, as they are unlikely to self-disclose and patients are reluctant to disclose this form of abuse to authorities, due to embarrassment, fear or even misplaced loyalty towards their doctor.
Reviews involving doctors in different countries over a number of years suggest that between 0.2% and 10% of doctors admit to a sexual relationship with a patient and that around 1.6% doctors are sanctioned.
These doctors are more likely to work in general practice, psychiatry and obstetrics and gynaecology, reflecting the greater likelihood of physical contact and/or psychological intimacy.
A striking feature of the literature into sexual boundary violations is the absence of ‘red flags’, meaning that the doctors who perpetrated the violations had no features that could be identified through screening tests.
Except for rape, cases occurred without obvious signs of a personality disorder in the doctor and involved both patients who were particularly vulnerable as well as those who exhibited no special vulnerabilities other than being a patient.
While the literature is rich in examples of doctors who commit sexual crimes against their patients, there is very little actual data with respect to understanding their motives or any predictive personality characteristics.
I think it is fair to say that currently there is no actual reliable way of predicting which of the many hundreds of thousands of doctors will commit crimes of this nature, given the only reliable discriminant is being male.
It is difficult to assign motives to why doctors conduct themselves in this manner, other than the performance of the sexual act itself. Nevertheless, as with all of life, it’s not always so clear cut.
The daily practice of medicine is filled by opportunities to develop intense emotions between the patient and clinician. These emotions engendered might include hostility, aggression, despair or even love.
Patients can evoke powerful responses in the clinician who cares for them; these responses are called counter transference. If recognised and understood, they can be a tool in gaining a better understanding of the patient.
If not – as, for example, where the patient evokes feelings of love in the clinician – it can have destructive and damaging sequelae.
Doctors themselves, in a vulnerable position from their own life events, might find themselves in a psychological state where compromising their professionalism is possible.
This might be where the doctor becomes emotionally entangled with a patient, due in part to what has been thrown up by the doctor’s own life experiences during the doctor-patient interaction.
This is why it is so important that we have access to supervision, especially when we are in susceptible psychological states.
Sexual relationships between doctor and patient are often the culmination of a series of ‘boundary crossings’ where the first one might be perceived as entirely innocent; for example, seeing the patient for extended appointments at the end of the day or giving one’s personal phone number.
4I forgot (dishonest)
This category includes omitting to do things that a doctor is mandated to do. For example, have up-to-date medical indemnity, renewing necessary training – such as Section 12 Approval for conducting assessments under the Mental Health Act – or forgetting to inform the GMC if one obtains a caution or conviction.
Dr Clare Gerada (right) is medical director of the Practitioner Health Programme, London, and a former chairman of the RCGP