I have been a GP for over 20 years. Two years ago I referred myself to the GMC after realising that I had failed to maintain an appropriate professional boundary with a patient. My fitness to practise was found to be impaired. I have been allowed to continue working but with conditions placed upon my practice, which include regular clinical supervision and a requirement to demonstrate my learning.
‘Patient A’ had a history of significant childhood trauma. She would tell me what a good doctor I was — how nobody had tried so hard for her before and how lucky my patients were to have me as their GP. She would often self-harm and share fears that her abusers would re-appear. I unwisely decided to share my personal contact details, telling her that if she needed help in a crisis she could ring me.
I replied whenever she made contact and would squeeze her in at the end of evening surgery. When she moved away I agreed to her suggestion that we could stay in touch. We met up a few times, but I soon realised that I’d made a mistake. I failed to appreciate the extent to which she had become emotionally dependent on me.
MAINTAINING A PROFESSIONAL BOUNDARY
The GMC’s ethical guidance for doctors1 is quite clear on our professional obligation to maintain an appropriate boundary between us and our patients. This requirement can conflict with a well-meaning desire to offer what we might consider to be a compassionate and humane response to a fellow human being who is suffering.
My intentions were only ever to help but I had been unable to appreciate the boundaries that were being crossed. I had an obligation to recognise what was happening but failed to do so. At work I had been feeling isolated and under-appreciated. As a consequence, I disengaged from team working. I sought fulfilment from helping my patients as much as I could.
Colleagues weren’t supporting each other or holding each other to account. This patient often appeared on the end of my evening surgery lists, yet nobody seemed to notice or thought to ask if I was struggling to manage her. Around the same time another patient took his own life. His family blamed me and I blamed myself too even though the Coroner’s Inquest found no fault. Traumatised by this, when thoughts of self-harm and suicide were shared by ‘Patient A’ I became even more responsive and attentive.
COGNITIVE DISTORTIONS AND SELF-AWARENESS
At the Medical Practitioner Tribunal Service hearing it was confirmed that my actions amounted to serious professional misconduct and had caused the patient harm. I could easily have been suspended. Therapy has helped me to understand myself better. Through my actions I was subconsciously fulfilling my own needs although I didn’t realise it at the time.
Cognitive distortions are unhelpful thoughts that distort our perception of reality. We believe these thoughts to be true and act accordingly. I thought that what I was doing was in the patient’s best interests. I successfully convinced myself of this, despite evidence to the contrary. I have worked to define my core values, deeply ingrained principles that inform the decisions each of us make. We tend to act in a way which ensures that our core values are met. This may cause problems if they conflict with our professional obligations.
My work colleagues have worked hard to reintegrate with each other. We have started to look after and to support each other much more. Workplace supervision has been invaluable. Reflecting with a colleague on consultations during which I have felt a strong emotional response has helped me to understand why I might have found myself feeling that way. Such peer support is mutually rewarding — not only helpful for me in understanding my own vulnerabilities, but also an opportunity to share my learning.
Certain patients have particular resonance for each of us. We may, for example, pick up on the vulnerability expressed by patients who have suffered childhood abuse and feel a need to ‘protect’ them. My new professionally boundaried way of working feels empowering. I am aware of a greater emotional resilience.
Doctors are human beings with emotions that we may not seek to have, but which we must learn to recognise and maintain control over. We must watch them carefully and not allow them to drive our responses. We have a professional obligation to do so.
- © British Journal of General Practice 2020
