We thank you for sending in your questions in the comments section during the 'Keeping within professional boundaries' webinar. In order to address all your unedited questions, the following is a summary we have split into a selection of general categories:
1. Rural and remote clinical practice
Sample questions:
- I am a country GP and served in the army with a patient, friends with the patient, a patient is my tradesmen & he is my CFA instructor. Is there any recognition that there must be some overlap because there are not enough people to separate my life completely?
- My neighbours and acquaintances from town are my patients. My immediate family and friends have their own doctor. I advise colleagues or acquaintance when they ask me to be their doctor, of the need for us to be transparent etc., define talking medical things in clinic and not socially, small town limited Dr. choice and allow them as my patient.
- Please comment about rural/remote practice where we shop & socialize together.
- How do you approach situations where people from the same community specifically come to see you because of your cultural background but, due to the small size of the community, you almost always know either the patient or members of their family outside of the professional situation?
MIPS' advice
There have been several notifications where members have encountered difficulties (eg complaints from regulators or family members) when the professional boundaries are blurred. It is essential to be objective, impartial, and unbiased when delivering medical care.
The 'gold' standard is to have a treating relationship entirely separate from any non-clinical contact. This approach is often possible in urban and suburban practice, but this is not always possible in rural settings.
Sexual relationships *always* must be avoided with patients (and their relatives).
In accordance with the dental and medical boards' Codes of Conduct guidelines, never use your professional position to establish or pursue a sexual, exploitative or other inappropriate relationship with anybody under your care. This advice includes those close to the patient, such as their carer, guardian, spouse, or child patient parent.
Using the plumber patient as an example – the plumber (who might be the only one in your rural town) might offer to fix a leak in your house for free. You might accept. He might then see you asking for S8 medication, and you might feel pressured to prescribe given the favour he did for you.
It would have been preferable to have responded to his offer of free work by saying, "Thank you for the offer, but we must maintain a professional relationship as I am your doctor. I, therefore, cannot accept your offer of free work. I will pay instead.” This approach would make it easier to be objective when the patient is in your consulting room.
2. Use of chaperones
Sample questions
- When there is no chaperone and it is potentially your word against theirs, is it safe to decline certain services on account of no chaperone?
- What if patients decline a chaperone? Will just documenting it on the notes protect you?
- Do you recommend always having a colleague/nurse/other present in the consultation?
MIPS' advice
In circumstances where you do not feel comfortable doing an intimate examination without a chaperone, and there is no chaperone available, we recommend that you inform the patient of your standard practice.
You can offer to undertake the examination at another time when a chaperone is available.
Alternatively, you may proceed with the intimate examination if a colleague is willing to be present in the room with you to reduce the inconvenience to the patient.
If you decline to perform the examination at the time, be sure to advise the patient why the examination is necessary. The patient must be fully informed of the need for an investigation, when it is timely to occur, and why.
Ensure you carefully document the advice that you have provided.
3. Gifts
Sample questions
- Sometimes patients want to bring gifts, like a bottle of wine, chocolates, flowers or food. Should a doctor or other health care professional accept that? If not, what are the strategies to politely decline these offers? A patient might be a professional, for example lawyer or plumber, whose services are needed by the treating doctor. Are there certain pitfalls in this situation?
- As a GP, is it inappropriate to accept gifts from specialists that you have referred patients to?
MIPS' advice
A small gift provided in such genuine circumstances is unlikely to lead to any concerns around boundaries from regulators if it came to their attention at all. But it might sometimes be challenging to know when a 'small gift' crosses the threshold of a 'big gift'. For example, receiving chocolates or wine at Christmas is quite different from gift tokens of $200 or a patient paying the school fees of the doctor's children or naming the doctors as a beneficiary in their will.
The safest approach is to steer clear of any beneficial financial arrangement with any patient.
4. No patient friendships
Sample questions
- Are non-sexual friendships with patients now completely forbidden? If not, where are the new boundaries?
- Is it accepted to use messaging applications such as WhatsApp as a means between doctor-patient in relation to their medical conditions?
MIPS' advice
No – but sexual relationships are. It is all about the misuse of the power imbalance to your advantage.
AHPRA states: "It is recommended that messaging applications such as WhatsApp are not used for communication regarding clinical matters".
5. Clinical consultations
Sample question
- Is it necessary to state every part of the body we are examining and get consent? And is there a need to document in the health records as verbal consent?
MIPS' advice
No, but you should be specific in the case of intimate examination. We strongly recommend that you advise patients before any physical contact, the type of examination you are performing, its nature, and its purpose to ensure that you have the patient's informed consent.
It is essential to document your assessment and your findings, and we strongly recommend that you record the consent to any intimate examination.
Always document your consent process, particularly for intimate examinations.
- Can I record myself or video myself in consultations to protect myself from fabricated allegations?
MIPS' advice
The law differs between States and Territories but most prohibit recording of consultations without the specific consent of the patient.
Ensure you contact MIPS for 27-hour Support and Advice on 1800 061 113 in the event of an adverse event or where there is a threat of a claim or notification made against you.
Resources
Good medical practice: a code of conduct for doctors in Australia
