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.