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HEALTH practitioners need more specific advice from their Colleges and governing bodies to determine what defines a “former patient” and how to navigate a safe and appropriate conduct a non-therapeutic relationship, says an Australian expert.
Professor Jenni Millbank, Distinguished Professor of Law, and Director of the Law Health Justice Research Centre at the University of Technology Sydney, told InSight+ in an exclusive podcast, that there was a common misconception among health practitioners that a sexual relationship with a former patient was okay.
“If they find themselves attracted to a patient, if they don’t believe there’s a very serious power imbalance with the patient, and the patient doesn’t believe that either and they mutually affirm that with each other, [there is a fairly common misconception] that if the health practitioner says ‘let’s just stop me treating you and you won’t be my patient and it’ll be fine’,” said Professor Millbank.
“That’s really where a lot of practitioners can come unstuck.
“Some of these relationships are understood by the parties involved as genuine romances and they don’t see themselves or understand themselves to be behaving abusively. But at the same time, they’re not getting outside advice.
“They’re not stopping and putting in place a process whereby there’s any kind of check or balance, and they’re not making sure that the patient is getting health care from someone else.
“So, with all good intentions in some of the cases, that situation then snowballs into one of secrecy and deception and records being covered up or falsified. Then when it all goes wrong and comes out, it can be very harmful to the patient and the practitioner hasn’t themselves been able to access any good guidance or assistance.”
Psychologists, Professor Millbank said, lead the way in terms of guidance for practitioners in this area.
“Psychology has done two things. One is they have set a 2-year period [in which relationships with former patients are prohibited], but the other thing is they have set a process,” she said.
“They actively investigate – what does this mean for the patient? What does this mean for the professional? Each of them should have separate advice and that process should be a managed process, that involves open disclosure.
“It’s not just ‘time on the bench’.
“It would be more helpful I think, if practitioners were able to access advice and support and have those kind of processes clarified upfront, rather than, getting a sense from a legal decision after it’s all gone wrong a couple of years later.”
Professor Millbank said that it was female health practitioners who more often “had a blind spot in terms of their own position of power as a health practitioner”.
“They were much more likely than male health practitioners to characterise what was happening as a romance, as okay,” she said.
“Male practitioners are more likely to be involved in relationships with multiple patients or clandestine relationships with patients.
“Female practitioners are more likely to have an idealised romantic notion that this was fine, this is their true love. They are more likely to be open about it, but they were also more likely to not get it. That did involve them in many cases of using a position of power.”
Professor Millbank told InSight+ that medical education needed to involve specific advice on this subject.
“Every profession has a kind of, ‘don’t do this’ in their educational process,” she said.
“But it needs to be more developed and it needs to be more about what do you do if you find yourself in this position. How do you avoid getting yourself into this position and what do you do if you, for instance, believe yourself to be genuinely in love with a patient or a former patient or family member of a patient. There has to be a process, a process of support and supervision to assist that person to get out of that situation without causing damage.”
Professor Millbank is the author of a Perspective published by the MJA today.
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I think the only way a relationship with a former patient would work is if the patient and former doctor (having terminated treatment, and having NOT had any direct discussion of the potential of them being in a romantic relationship), casually met 2 years or more later and both are single. Zero contact in the time frame between treatment and meeting via kismet.
Psychiatrists should never be permitted to have relationships with ex patients, regardless of how much time has gone by.
Is there a way a doctor patient relationship can be approved and the doctor can be legally be protected from professional misconduct if both parties consent and it’s legally drawn up and documented as consensual by both parties.
( Assumption doctor has already referred patient to another practitioner)
Informed consent by both, no force or coercion and the dr – patient relationship to be terminated and handed over to another clinician.
What must a young single doctor in a remote 1 doctor country town, 24/7 on call with minimal time for holidays do, if he / she is looking for a life companion or soulmate ? Is any prospective relationship with other singles in this town out of bounds because the doc has seen the person for a flu or small laceration repair to a finger …?
What about the many relationships that last for years between e.g. a teacher and a pupil (it happened with 1 of my fellow – female high school classmates … and they are still married 36 yrs later)…
Airline pilot and an air hostess, counsellor and the patient, reverend/pastor and a member of his congregation….
Lawyer and her client …, company manager and his junior colleague or secretary …
Doctors are also human, and life happens…
I condemn any exploitive relationship between therapist and patient, which ever way … but there should also be allowance for other relationships between the doctor and patient… e.g. friendship as members of a social or hobby group or club, and if fate would have it … perhaps a carefully negotiated romantic relationship; with the monitor of a senior colleague or mentor; with the blessing of AHPRA if persued under accepted guidelines.
Our Big Problem, which needs a legislative fix, is that AHPRA was founded on a “Never-Again” footing by people who held that kind of philosophy, some of whom had personal Never-Again grudges against somebody in their own past (not a doctor).
Those same people may have moved on by now, but the statutory stance is to lean into the space formerly enjoyed by health care practitioners, with prescriptive and proscriptive intent.
And the way the Law reads is that they cannot NOT look into any trivial complaint. They *must*.
As you know, it also empowers them to take advantage of their pretext to then rummage through all unrelated aspects of a practitioner’s set-up and past files etc. Compiling as many infractions as are detectable, trivial or otherwise.
I think this is inappropriate for 97% of our colleagues. But it is applied to all and sundry, because we are all suspects.
What gets missed is the wastefulness of the compensatory behaviours … The way already-perfectionistic practitioners practice defensively and overly carefully because of this ever-hovering sense of threat. I don’t like it.
This is too proscriptive; I had a romantic relationship with a former patient, who was also a nurse in the hospital I worked at. The therapeutic relationship had been a once-off some years before. I started on the premise that I would not see her again as patient, then had an informal chat with the chairman of the State Medical Board ( as it was then, pre-AHPRA ) indicating our desire to pursue a relationship on this basis. I carefully discussed all the implications with her as well. I was given approval by the Board. . In fact the relationship did not last, but I felt i had gone about it correctly , and we parted amicably . This must crop up all the time in country towns where there is only one doctor. Flexibility and the ability to take into account individual circumstances is needed, not a blanket ban.
That relationships between a doctor and a patient or former patient are a cause for AHPRA disciplinary hearings is only in part due to the need to act in individual circumstances.
There is also the broader picture. Every patient needs to be comfortable that their doctor will under no circumstances be seeking romance with them. Anything short of that leaves a possibility for misunderstanding. The converse is also true, that some patients would do well to understand that they may not contemplate a relationship with their doctor, no matter how empathic and warm that doctor appears during a consultation. The absence of that very rigid guideline (meaning that your doctor is fair game) may well encourage even more inappropriate and unwanted advances from a patient, and subsequent trouble.
COI: over the years I have been aware of being the object of an unwanted advance by a patient on many occasions. Fortunately all were easy enough to diplomatically ignore and avoid unpleasantness.
Transference (noun): the redirection of feelings about a specific person onto someone else (in therapy, this refers to a client’s projection of their feelings about someone else onto their therapist). Countertransference (noun): the redirection of a therapist’s feelings toward the client.Nov 11, 2019
Relationships with patients were always BANNED in my medical education. Have we forgotten the above reference – transference of feelings rather then true feelings.
There are many non patients rather than complicating life and relationships and running the risk of running the wrath of AHPRA , lawyers etc.
Just because some relationships survive is not justification.
I have never understood the concept of “power imbalance” which is taken as real.
I live in a world of informed consent, where if I do a 2-stage procedure, a major reconstruction and a minor subsequent removal of a wire, I need a separate written consent form for even the most minor second stage.
Similarly, if the patient consents to amputation to treat his cancer, or refuses consent, I must accede to his wishes. I can cajole, but not coerce, irrespective of the knowledge imbalance (that is real and quantifiable) in medical matters.
The patient is not my property, nor my vassal, but my employer.
The phrase ‘my patient’ is not proprietorial, but shorthand for a one-sided power relationship. The days of Sir Lancelot Spratt, bullying patients into submission, are long gone.
I am a hired contractor, for a long as the patient chooses to engage my services, and I can be dismissed for no reason whatsoever, with no notice and no recourse. He can even dump me between the stages of a 2-stage procedure, and again I have no legal means of performing the second stage. I can (and legally must) tell him that the retained intraosseous wire carries risks of osteomyelitis and systemic sepsis even to the risk of death, but any ‘power imbalance’ is 100% on his side.
I can tell him to stop smoking, and he can laugh at me and refuse.
There may be circumstances like the one doctor town, or the only sub-specialist in a regional centre, where the patient has no effective choice of doctor. However, even in that circumstance, if the doctor develops feelings for the patient, or the patient expresses feelings for the doctor, the advice of MDOs and regulatory bodies is to end the therapeutic relationship.
The United Nations’ Universal Declaration of Human Rights is specific:
Article 16.
(1) Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family. They are entitled to equal rights as to marriage, during marriage and at its dissolution.
(2) Marriage shall be entered into only with the free and full consent of the intending spouses.
(3) The family is the natural and fundamental group unit of society and is entitled to protection by society and the State.
If a patient can give free and full consent to an arm amputation, potentially fatal chemo/radiotherapy, a pelvic exenteration, a heart/lung transplant or a hemispherectomy, why can they not consent to a relationship?
And I’ll echo Sue Ieraci’s comment, I have no personal experience nor do I intend to. But a good friend is coming up to 40 years’ marriage to an ex-patient. She still attempts to treat him for his own good, he still remains an obstinate bugger and declines wise medical advice.
One of the issues with answering the question “is it EVER ethical to develop a relationship with a former patient?” is that the regulatory authorities selectively become aware of situations where things go wrong. Our oversight system CAN become more sophisticated in its handling is this situation if evidence emerges of the characteristics of “healthy” relationships. Some aspects should be considered givens: no relationships can be equal in power while the provider-patient relationship continues. However, it might be possible to define a pathway through which an ethically-based relationship can develop. This might involve several steps, including termination of the therapeutic relationship, commencement of an alternative therapeutic relationship, specific counselling etc. This might be a more pragmatic approach than “just don’t do it” – which is likely to be about as effective as it is for drug use and teenage sex. “If you are both absolutely determined that this is right for you, here is the safest way to proceed…” might be a better approach. (No personal experience here – just considering a nuanced approach).
Generally I agree. But Education by Whom? The College Policy nerds and AHPRA Control-hunters are not the right people. Please no.
Since it is psychological matter, why not get the Psychological Professional organisation to create resources and a practical online course, with reading resource to back it?
Nobody should have a relationship with their ex-lawyer either. Expect an avalanche of litigation. Perhaps we can have an algorithm on that one?
I am amazed by the simplistic ipse dixit statements that any such relationship is unethical in all circumstances. Ask yourself seriously, if you had to choose between Medicine and a marriage to the right person, which would you choose?
Four rules should be followed.
1. Relationships between psychiatrists, obstetricians, paediatricians or occupational physicians, and former patients, are always unethical. The nature of these branches of medicine precludes informed consent.
2. The therapeutic relationship must have ended on amicable terms with no disputes outstanding. This would normally involve a formal referral to another doctor and the passage of a reasonable time. This also requires consideration of the nature of the therapeutic relationship; a radiologist who reported on the patient’s foot x-ray is not the same as a respiratory physician treating obstructive sleep apnoea.
3. Appropriate care must be available to the doctor’s new partner, without recourse to the doctor. Particular attention would be needed in rural and remote areas, and with patients with chronic disease.
4. Both parties are aware of the risks and have made an informed decision to assume them. Unexpected sequelae of therapy, or serious disorders not having been detected, would result in strain on a subsequent relationship. Particular reflection would be needed if the raising of children is contemplated.
But Doctors and Nurses always live happily ever after with their patients/lovers in the movies with no consequences. Are you telling us things are different in the real world ?
I know of at least 4 long standing relationships between the doctors and an ex-patient. I am not one of these. Four married and I know that these all proceeded to longlasting, significant commitments, some with offspring. Three certainly sort advise from colleagues before their liason, and formally discontinued all therapeutic relationship.
This is quite different from exploitation by the therapist without any commitment.
Having a documented process is a great idea