Medico-legal - Going that extra mile

Sometimes medics can do too much for their patients, says Dr Jim Rodger of the MDDUS.

Photograph: Getty Images
Photograph: Getty Images

Doctors who display a warm, friendly and reassuring manner with their patients are more effective. There is no doubting this and research bears it out.

Displaying appropriate empathy makes patients more open with symptoms and concerns and encourages them to become more engaged in their own treatment - all of which can lead to improved therapeutic outcomes.

However, sometimes doctors can be too helpful. GPs in particular can develop close relationships with patients in both clinical and social terms.

A natural increased level of compassion for people in difficult circumstances may blind the doctor to the risk of close involvement with matters that are not strictly clinical.

GPs may have feelings of sympathy or empathy for patients, and the job depends on that, but be cautious not to go a 'step too far'. Going that extra mile for patients often backfires and can cause more trouble for the doctor than they could ever imagine.

We have examples of doctors who have gone to extraordinary lengths to see a patient referred, even hand-delivering letters to homes after work or offering to take patients in their own cars to appointments, only to receive a letter of complaint, to their astonishment, two weeks later.

Some doctors will take great pains to ensure access to medicines that patients have read about or seen on the internet, or they make efforts to see patients prescribed banned medicines (such as co-proxamol).

Beyond healthcare
Some doctors will try to give help and advice to families regarding matters such as matters as powers of attorney, capacity or incapacity, or the validity of wills. This must always be avoided; financial and other such personal concerns need professional legal advice, not that of a doctor. To become too closely involved in such matters risks being embroiled in legal proceedings.

There have been times when doctors, because of their concern for patients or their surviving carers, have thought to intervene in insurance claims that might be prejudiced by possible non-disclosure. All such reports must be factually true and supplied to an insurance company irrespective of their effects on the family. To do otherwise risks censure from an insurance company or the GMC.

Legal matters
Custody battles are another source of trouble. One may be pressured to take sides in such matters or asked to intervene. Close involvement with the perceived rights or wrongs in these situations is dangerous.

Parents must be directed to the right place to resolve these matters - a lawyer.

Finally, there have been examples of doctors who become embroiled in correspondence with a patient's employer and decisions about suitability or otherwise for work or in relation to work-related illness.

Unless a doctor has some special expertise in occupational medicine they should tread carefully in fitness for work, except in so far as they can comment in general terms.

Empathy and detachment
Dilemmas touch at the core of what it means to be a doctor. Today such 'boundaries' are formalised in guidance from bodies such as the GMC. The main issue for the GMC is one of trust.

The GMC guidance comments on the potential 'imbalance of power' in the doctor-patient relationship.

Vulnerable patients can become over-reliant on doctors and it can be hard not to let this spill over into non-medical aspects of their lives.

This is not to suggest that helpful doctors are necessarily pursuing exploitative relationships with patients; rather that when therapeutic boundaries are blurred it can become a matter of perception. A patient's over-reliance can become dependence with a strong emotional component.

At arm's length
Getting drawn into the life of a patient can also raise questions of competence. The GMC's Good Medical Practice states: 'In providing care you must recognise and work within the limits of your competence'.

Advising a patient on how to deal with financial debt may be tempting but it's opening the door to criticism when things go wrong and the patient makes a complaint.

Doctors must also consider the effects on themselves of not maintaining a healthy emotional disengagement with patients. Burnout and compassion fatigue are real issues for GPs. Today much of the mental health treatment in the UK is provided in primary care.

GPs are well suited to this role, having a holistic view of patients' physical, social and psychological backgrounds. But some patients come with a tangle of interrelated problems.

Some doctors may feel an ethical duty to sacrifice their own health and feelings for the good of their patients.

It is ironic but not surprising that these 'good' doctors are those most susceptible to burnout and compassion fatigue.

Expectations placed on GPs can at times seem limitless. Only those able to manage these expectations and accept their limitations will avoid the common pitfalls of the profession.

  • Dr Rodger is a medico-legal adviser and head of professional services at MDDUS
  • This article first appeared in the Medical and Dental Defence Union of Scotland publication, Summons.

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