Practice dilemma - A patient invites you out to lunch

11 June 2009

The Dilemma - One of your patients is a wealthy retired banker.

You have built up a good relationship over the past five years, as you have seen him and his wife for management of their various chronic diseases. He has frequently asked about your husband and children, mainly because he has children and grandchildren of similar ages. At the end of one consultation, he invites you to go for lunch at a local restaurant one Sunday. He says he would like to extend the invitation to your husband. You know that this restaurant has an excellent reputation and you are initially keen to accept.

However, as he is your patient, what should you do?

A GP'S VIEW - Dr Alison Glenesk is a GP trainer in Aberdeen
Lunch and dinner invitations at first glance seem to come into the same category as Christmas gifts. Some patients like to express their gratitude in this way, particularly if the doctor has helped them through a bad patch. Most of these gifts are appropriate and, provided they are not excessively expensive, should be received in the spirit in which they are given.

On consideration, however, a lunch invitation is subtly different. First, I would actually have to agree to go, which could be seen at tantamount to my accepting a subtle change in my relationship with my patient from the professional to the social, potentially making it difficult to re-establish our doctor-patient relationship at a later date.

Also, if the patient will be paying, am I then beholden to him? Will he think I owe him more of my time, or my agreement to treatments or referrals I know deep down are not in his best interest? Consider if it will be possible to maintain objectivity if the relationship is changed in this way.

I might initially be relieved that he is involving my husband, as this at least obviates potentially sinister motives for the encounter; however, I am not sure this is appropriate either.

It is very probable that my patient's interest in me and my family is completely innocent. However, the GMC's guidance states: 'you must not accept any...gift or hospitality which may affect the way you prescribe for, treat or refer patients.' (Good Medical Practice, paragraph 74) I would use this to turn down his kind invitation with regret, while maintaining my professional relationship with him.

A MEDICO-LEGAL OPINION - Dr Jayne Molodynski is a medico-legal adviser at the Medical Protection Society
Although an invitation such as this may be appealing, it is important to consider the ethical issues involved. While you may not wish to cause any embarrassment by refusing, doctors must remember that keeping a boundary between their professional and personal lives is vital.

The GMC provides guidance in their publication Good Medical Practice. It states that doctors must not use their professional position to establish or pursue an emotional relationship with a patient or someone close to them. While this advice does not appear to be directly relevant to this situation it does raise questions about what constitutes an improper relationship with a patient and identifies that doctors need to be cautious in this regard.

It may seem entirely appropriate to accept this apparently innocent invitation but it is important to realise that there may be unforeseen consequences. Unfortunately, it is difficult to predict how the relationship may progress and how it may affect your ability to maintain professional boundaries.

The patient may consciously or subconsciously seek to influence you because of a perceived special relationship. For example, you may find it difficult to refuse this patient's requests after you have accepted their hospitality. If you think that there is a risk that your professional objectivity could be compromised, it might be wise to politely decline the invitation at this stage to ensure that the professional doctor-patient relationship is protected.

This will also ensure that you are not leaving yourself vulnerable to criticism from colleagues or the GMC.

A PATIENT'S VIEW - Elizabeth Brain, member of the RCGP patient partnership group
Given that you have a good relationship with your patient, to refuse his invitation outright could be construed as churlish and might damage your professional relationship with him and his wife.

You should therefore accept his invitation if you are able.

There could be several reasons why he invited you and your husband. It might be entirely innocent and be motivated by a genuine friendship that he and his wife have toward you, and they may wish to extend this to your husband. Alternatively, he may want to do something to support your GP practice either financially or in kind.

If anything is offered, even if apparently in good faith, do not commit before consulting with your colleagues.

However, as a precaution, it would be prudent to brief your practice colleagues, preferably in writing, of your intent to accept a lunch invitation with a patient and to seek their opinions, just in case there have been past instances of this type with other patients. After the luncheon, you should report back to your colleagues at an early opportunity with any issues.

Finally, enjoy the lunch.

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