My medical defence insurer wants to protect me from myself. The insurer invites me to attend a webinar titled, Keeping Professional Boundaries. I entered medical practice as I entered life: I wanted to break down the barriers that kept people apart. “Only connect” was the motto of the great E M Forster. It was my motto too.
In recent years, AHPRA has been writing to me, warning me to maintain necessary distance from patients. I should avoid initiating any physical touch of a patient, other than when clinically necessary. I must not treat friends, I must not treat family members, I should not meet a patient for coffee or a drink or a date, nor for a dalliance nor for a sexual relationship. Realising that the world has changed I register for the webinar.
The webinar began with a playacted scenario of a young male doctor’s consultation with a youngish woman. The doctor is a good-looking male, personable and competent. His patient is an attractive young woman, perhaps slightly older than the doctor. At the conclusion of their consultation the patient asks, “Do you have any more victims today?”
The doctor hesitates and the patient clarifies: “Am I your last patient today?”
“Yes, as it happens.”
“Would you like to go somewhere and have a coffee together?”
At this point the youtube stops and the watcher is presented with three possible responses the doctor might make. One only is deemed correct.
1. The doctor assents. It’s innocent enough. Sharing a single cup of coffee is not improper.
2. The doctor informs the patient politely that he cannot accept. Further, he states the professional relationship has broken down and he must not see her again as her doctor, but must arrange for her future medical care with another doctor.
3. The doctor informs the patient politely that he cannot accept. He states, ‘We have professional guidelines which we must follow.’
To me the answer seemed simple. But the scenario made me think over the past 52 years of being alone with people of all genders and trusted by them. Form more than half a century I’ve tried to remove barriers. None of my patients, however, invited me for coffee, so I had no practical experience of the scenario.
I recalled an event that occurred perhaps a dozen years ago. I received a phone call from a previous patient whom I first met when she was one week old. She remained my patient through childhood to adulthood. I treated her father for his rare disease, which eventually killed him.
The young woman studied Medicine and when she graduated, she invited me to attend her graduation ceremony, I supposed, in loco parentis. She became engaged and she invited my wife and me to attend her wedding. She trained as a GP and started practice in the country. I didn’t see her for some years. Now she rang me, asking if she could consult me professionally. She was unsure how to approach a possible problem affecting her little boy.
I offered her the first appointment of the next convenient day. The young woman accepted. Then I said, ‘If you can come half an hour earlier, we can meet for a cuppa beforehand.’ My patient accepted enthusiastically. At the café, delighted to see each other again, we embraced, sat down, drank coffee, talked about our work and our widowed mothers then crossed the road for our consultation.
The same day I opened a letter from AHPRA which arrived in the mail. The letter warned against socialising with patients, specifying the dangers and the power imbalance that prevailed even in meeting for coffee. The same letter emphasised the need to avoid non-clinical touch. I thought about the hug with which my patient and I had greeted each other that morning.
This brought to mind another occasion in which I had transgressed. A religiously devout young woman whom I treated through childhood and adolescence moved interstate to train for the ministry. Her parents had been my patients before her. Her father was the first patient I referred for total knee joint replacement. The operation was a success but he developed an infection and died a week later, of septicaemia. His daughter was then a teenager.
The young woman studied theology, married and served a flock in a distant city and I did not see her for quite some years. She returned once to Melbourne to seek my help with infertility. She was married happily to her first boyfriend, himself a minister in the same community. I asked some questions then placed some calls and referred her to my favourite genius. Years after that she turned up again at my country practice on the outskirts of Melbourne. I was delighted to see her. We sat down and I asked her about her life. The couple had been blessed with two small children.
The conversation turned to her health. She said, “I found a lump in my breast.” I examined her and felt the lump readily. It was hard, a bad sign; it was not mobile, another bad sign; the overlying skin was puckered, a further sinister sign.
After she had dressed, we talked. I answered her questions: Yes, it was worrying. Yes, it was probably cancer. We talked about treatment, about biopsy and tests, about choice of specialists. She asked me about the prognosis. I answered as well as I could. I asked her about the age of her children.
I placed some phone calls and wrote a referral letter. We spent well over an hour together, the visit spilling falling at the end of my morning’s work.
I felt shattered.
The young woman stood to leave. I took her in my arms and held her a moment then released her. But she held me for some time, her head resting against my shoulder, her body heaving with sobs. At length she wiped her eyes and said, “That’s what I crossed the country for.”
Looking back at that encounter I realise that this was the first time I had initiated such conduct. I had acted on an impulse, in response to which my patient had told me how much it meant to her.
I have socialised with patients, I have drunk coffee with them (and in one case, eaten pancakes with an ex-patient’s at her invitation). I have treated close friends and, apprehensively, I continue to do so. I have walked the primrose path toward the eternal bonfire.
In recent decades lawyers, teachers, nurses, ministers of religion, therapists and doctors have all been guilty of extremely harmful acts. In response to those wrongs all professionals have been warned to protect those who are vulnerable. Power resides with the professional. Power corrupts some. As a result, society is wary of abuse. And all of us in professions have been trained to mistrust ourselves.
I think about my Dad in his years practising as a GP in a country town. His patients were his friends. His friends were his patients. After we moved from the country to the city some of those friends drove hundreds of miles to consult him. I think of the many doctors living and working today in small communities. The AHPRA rules (or ”guidelines”) would, if followed, socially strangle a doctor and in preventing great harms to patients, do much harm to practice.
My insuror’s webinar gave clear and absolute guidance to members. We would be obliged to decline the coffee, and we must bring an end to the relationship forthwith.
I am guilty of great error: I still trust myself.
I no longer belong in a role which has long been my home.
howardgoldenberg 
A doctor, even older than I, wrote the following:
“howard, good to hear from you.
as usual you raise difficult questions to the surface. Like you ,I worry about these issues. Being ethical is a way of being, and questioning, not following a set of rules. You know this , indeed exemplify it…it is at the core of your Judaism. I suppose we need rules as broad markers, but in the end they can ossify and harden into unkind , and ,yes , unethical postures and the perils of literal and fundamentalist punishments.:lots of rules and no forgiveness!
Much to talk about here, and it would be good to coincide.”
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A wonderful, heart-warming account of what life is meant to be about. I was so lucky to be a small part of your life and experience your wisdom, your care, and your obvious affection for family and friends. You took a chance and welcomed all with open arms and the world is a better place for it.
Must get together again!
Mick F
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Mick!
I woke up this morning and asked myself if i’d go for a run.
The answer i gave myself was no. I ran (actually, plodded) for two and a half hours yesterday. Today I’d just do the old man’s run to the toilet and hope to arrive in time.
But as I thought of running, my thoughts turned, as they do quite often, to Mick Fenelon.
He was a far, far better runner, but he was always willing to run with me. Those unforgettable runs at the prom!
Was Mick still running?
Probably he’d moved on to some other sport at which, as usual, he’d freakishly excel.
And here you are.
And here I am.
I’ll get in touch.
What a blessed day!
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For those on the precipice, it is the Dr Goldenbergs of the world and not the regulatory bodies who bring back lives from the brink. You absolutely still belong. I guess AHPRA has its place too. But compassion, wisdom and judgment like yours is needed now more than ever.
“Thank God for AHPRA!” said no one, ever.
“Thank God for Dr Goldenberg” said countless people over the decades.
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Dear Michelle M,
Not for the first time your response creates within me a strange mixture of pleasure, blushing, and confusion. At this late stage in my working life, i doubt myself as much as i did when i started. Truly my vocation (like any profession) comes with self-doubt; you want to be worthy of the trust of the person and of the community (including, as you wisely point out, AHPRA).
Kindly hyperbole like yours deeply soothes those doubts.
I’m embarrassed of course, by such praise, and too aware of my shortcomings.
The confusion arises because i’m unaware of what prompts the remarks. I can’t place the writer.
Let me give you an example: last year i was one of the senior doctors working at a mass vaccination centre. All present wore masks. I passed through the hundreds who sat and waited for their fifteen or thirty minutes for some reaction to the vaccine that would strike them down. A female voice came from a thin body behind a mask: ‘Are you Howard Goldenberg?’
I was.
The voice continued: ‘you saved my life last year.’
I doubted it: (I do very little acute emergency work.)
She continued: ‘I haven’t touched grog. I’m clean. I’m doing work that’s meaningful to me.’
It still wasn’t meaningful to me; I didn’t recognise her behind her mask.
Then she told me her name and I remembered. I recalled the thin young woman who saw me before and after her near-suicide. I remembered feeling frightened for her. We talked for a while and, feeling helpless, I asked her to see her the following week. She never came.
Now I understood why: she had found her own way. I felt flooded with gratitude.
Did I save her? It didn’t matter.
So, Michelle M, I can’t really learn what was useful that I did when we were together. You are still masked. I’m indebted to you and still confused.
I’d like to be able to understand.
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This unexpected response arrived from a doctor of a later generation:
“(This) brought up so many special memories for me and also makes me wrestle with my core beliefs to really care for patients wholistically and engage with them through connection. I believe this truly makes a difference to their lives rather than a superficial, disengaged consult touching on “just one problem”. To engage with patients, to develop trust, I think you need to connect and share. It is almost impossible to be human, living as part of a community, and maintain the barriers suggested by AHRPA etc.
I will defiantly be involved with my community as a GP, friend and a Mum of young kids in a country town. I will try my best to never take advantage of my position of power and avoid being taken advantage of as well. There are some patients I have known for years and I hug them when they need support or in celebration of good news with them.
I think it is not so simple being a GP living in your community.
I might be naive, but my intentions are good and honest. Screw AHPRA or my medical defense if they come and tap me on the shoulder.
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Someone sent me this:
“There was once a very frightened rabbit. It ran around in circles with sunglasses on. If the rabbit could not see you, then you could not see the rabbit.
The rabbit ran to the door of the wise doctor. Sometimes the doctor scratched his head and cricked his neck,
talked about the most amazing things. Told stories.
The rabbit would run from the consultation armed with a little more confidence having opened its eyes and looked into the compassionate face of the wise doctor. Was able to be a fully functional rabbit until the next fear filled episode would see it repeat the run back to the safety of the surgery.
What would have happened to that rabbit If that wise, compassionate, doctor had put on the facade of professional interaction (which was not a natural thing to him) and not shown the rabbit that there was a pathway in life that can lead without fear to a world of opportunity, creativity, trust and love without obligation?”
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How caring and honest you are Doff.
Nothing like baring your soul and sharing some of your wonderful and trusting times with people who eventually transcended from patients to close and caring friends.
Warmest wishes,
Barry The Big
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Thank you, Big barry, for this generous response
Love doff
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How caring and honest you are Doff.
Nothing like baring your soul and sharing some of your wonderful and trusting times with people who eventually transcended from patients to close and caring friends.
Warmest wishes,
Barry The Big
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Dear Howard, You saved my life with your kindness. As a teacher, I too struggle with the ridiculous legal overlays of a profession where one’s capacity to do the job well is directly linked to the development of warm and trusting relationships. As a single woman with little family, I observe a world that says it prioritises my mental health while at the same time depriving me, and millions of others, of the myriad of social interactions that once made me feel I lived in community. I often dwell on this as I put petrol in my vehicle because there’s no driveway service, as I check myself out of the supermarket, do my banking online and, lately, order my restaurant food using a QR code stuck to the tabletop so I don’t get to converse with wait staff. We are creating a world where a lack of social interaction and physical touch literally kills people. Sad.
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Helen!
So good of you to write and such wise observations
I recall warmly our times together
Thank you for writing, and doing it so kindly
I hope time has been kind to you
And teaching brings you the joy you deserve
Sincerely
Howard
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Hello, Howard.
Sadly, the world has chosen to go a certain way. Many decades ago, a wise person told me that a few years in a University can teach you a multitude of skills. However, those few years can never teach you what decades of care, experience and nouse will instil in you. You’re still the best GP my family and I have ever known. Anna and Sharon still talk about you from time to time. Thanks to dementia Pam only sometimes recalls your existence. I’ll never forget you. Thanks and God bless you.
Rudi
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Helen!
So good of you to write and such wise observations
I recall warmly our times together
Thank you for writing, and doing it so kindly
I hope time has been kind to you
And teaching brings you the joy you deserve
Sincerely
Howard
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Rudy
I was sad to read of Pam’s diagnosis: such a cruel condition!
All close to Pam must suffer with her
Thank you for responding as you did
Naturally we two find ourselves in fierce agreement
Blessings to you all
Howard
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Hello, Howard.
As I’ve often said to you, Dr Howard, you are the BEST!!!
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I definitely don’t agree with these bureaucratic warnings. If professionals all act in the manner suggested, all the time, we’ll loose the connections that we joined our professions for and that would be very sad for all. Let’s hope commonsense prevails and there’s a reversal of this lack of trust of professionals and an understanding that connections are what all humans want.
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Kirsty,
You write wisely
Your students are fortunate to have you
Affectionately
Howard
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You belong, it is the world that has changed, if more people were kind and warm like you, if more GPs and other doctors where feeling from their heart, and having empathy-everyone would feel trust and calm by their Doctor.
A trustworthy doctor with a heart of gold.
People are complaining that they cannot find a doctor that cares, but you do and that is very rare in today’s world.
Warm regards
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Thank you very much for sharing your story my friend. This is exactly what I’m suffering from, and you know my story very well.
God bless you and your family,
Farooq.
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