Relations with patients and colleagues

The GMC updated its supplementary standards guidance to complement the new edition of Good Medical Practice. 

In the second of its occasional series highlighting what has changed, the MDU’s Dr Catherine Wills focuses on maintaining personal and professional boundaries.

Establishing a good rapport with patients and colleagues is a valuable skill for every independent practitioner, but it is important to act with professionalism.

The GMC’s new guidance on maintaining boundaries emphasises the need to maintain respectful relationships, defines unacceptable behaviour in more detail and sets out how doctors should respond, especially those in a leadership role. 

It replaces two earlier documents: Maintaining a professional boundary between you and your patient and Sexual behaviour and your duty to report a colleague.

Here are the main points. 

Maintaining personal and professional boundaries

The GMC introduces the guidance with a reminder of the importance of appropriate personal and professional boundaries in all areas of practice. 

Not only must patients ‘be able to trust that medical professionals involved in their care will behave appropriately towards them during consultations’, but colleagues and staff must ‘feel safe and respected in their workplaces’ and ‘able to speak up when they experience or witness negative behaviours’. 

Personal relationships with patients (par. 8-17) 

The GMC explicitly forbids doctors from pursuing ‘a sexual or improper emotional relationship with a current patient’ or someone close to them, such as a family member.

It is less definitive about former patients, but says doctors must first consider all the factors that might make a relationship inappropriate.

This includes how recently the professional relationship ended, whether you treated them over several years or for a single consultation, whether the patient was – or is – vulnerable because of their age or the nature of their condition and whether you would be – or could be seen to be – abusing your professional position. 

Personal relationships with colleagues (par. 18-19)

The GMC considers consensual and reciprocated personal relationships between colleagues to be a private matter, although some hospitals or clinics might have their own Workplace Relation­ships Policy. 

However, it continues that these relationships should not be allowed to have an adverse impact on clinical practice or team environments and the GMC also warns about the risks of power imbalances and situations where someone’s training or career might be affected.

Inappropriate sexual behaviours (par. 20-23)

The GMC says that all forms of sexual misconduct are unacceptable from the criminal (rape, sexual assault) to unacceptable sexual behaviour. 

Paragraph 23 of the guidance gives examples including unwelcome touching, sexual gestures, leering, sexual banter, people asking intrusive questions or discussing their own sex life. 

Other examples include sending sexually explicit messages or posts, displaying sexually graphic images, spreading sexual rumours, making promises in return for
sexual favours, making sexual advances or ‘excessive or unwanted compliments on a person’s appearance’.  

It says that all ‘can have devastating impacts on individual wellbeing, psychological safety, patient safety, and medical professionals’ careers’. 

Later in the guidance (paragraph 34) it adds: ‘You must not act in a sexual way towards colleagues with the effect or purpose of causing offence, embarrassment, humiliation or distress’, which can include verbal or written comments and sharing images. 

Reporting sexual behaviour towards patients (par. 24-28) and colleagues (par. 32-39)

If a patient tells you about – or you have other reason to believe there has been – a breach of sexual boundaries by a colleague, you must raise concerns promptly and support those affected. 

When reporting concerns, you should usually respect patient confidentiality, but patient safety must come first, so there could be occasions when you need to breach patient confidentiality in the public interest. 

If that happens, you must tell the patient, unless not safe or practical to do so, and disclose only relevant information in line with GMC confidentiality guidance. 

In the latest edition of Good Medical Practice, the GMC has been more explicit about the importance of positive workplace cultures and respect between colleagues. 

It echoes that message here, stressing that any doctor who becomes aware of inappropriate sexual behaviours in the work­place has a responsibility to take some action – for example, by offering support, challenging the behaviour or reporting the behaviour depending on the circumstances. 

Those in a leadership or management role ‘must take active steps to create an environment where people can talk about concerns safely’. 

Leaders/managers must act on concerns to make sure such unacceptable behaviours are adequately addressed, people are supported and concerns are dealt with or escalated promptly. 

Speak to your medical defence organisation (MDO) if you are unsure about your responsibilities.

Sexual behaviour by patients (par. 10 and par. 29-31)

Around 15% of the 411 members who responded to a recent MDU survey were concerned that they had received an inappropriate gift from a patient or that the patient had an ulterior motive. 

Some reported receiving cards and flowers on Valentine’s Day, while others had previously declined gifts of perfume and lingerie. 

As our survey shows, it’s not uncommon for doctors to worry that a patient has developed an inappropriate attachment. 

In this situation, the GMC says you should try and re-establish a professional boundary, but if this isn’t possible, you may need to end your professional relationship. 

The MDU always advises members not to ignore advances by patients, as it could be taken as encouragement. 

Those in independent practice may or may not feel able to continue caring for a patient who has made an advance. 

Transfer their care

If you think it is possible to get the doctor-patient relationship back on track, politely explain that you need the relationship to return to a professional level, otherwise you will have to transfer their care to another doctor. 

Keep a record of the conversation and follow it up in writing, as well as a log of all contact from the patient. If you are unsure about what to say or if the patient doesn’t seem to have heeded your request, seek advice from your MDO.

For the first time, the GMC provides guidance on what doctors should do if a patient behaves in a sexual way towards you. 

If you feel safe to do so, it advises, tell the patient their behaviour is unacceptable and ask them to stop. 

If they persist or you feel unsafe, ‘excuse yourself from the encounter and seek help’ as well as reporting the incident and seeking support if needed. 

Annex: Good Medical Practice 

After the main guidance, there’s an annex which signposts readers to the relevant section of Good Medical Practice covering colleagues, culture and safety (Domain 3). 

We advise you to familiarise yourself with the new guidance and seek advice from your MDO if you have any specific concerns about professional boundaries or the behaviour of a colleague or patient. 

Dr Catherine Wills (right) is the MDU’s deputy head of advisory services