Navigating professional boundaries

Consider this scenario: Dr H is a GP working in a private clinic. Her brother has recently opened a private physiotherapy centre nearby. He asks whether she would be willing to “mention the centre” to suitable patients and gives her some brochures to put in the waiting area and hand out and is offering kickbacks for every patient referred.

Dr H agrees, as her brother is a qualified physiotherapist and she knows government run physiotherapy services can have long waiting times. Over the coming weeks during consultations with several patients experiencing musculoskeletal issues, she refers patients to her brother’s new physiotherapy centre and hands them a brochure with no mention of the family connection.

The nursing aid notices that Dr H is referring all patients requiring physiotherapy to her brother and asks her whether it might be more appropriate to provide a number of options for treatment both privately and through the public system.

Dr H insists her recommendations are clinically appropriate and that it benefits the patient. That night, however, she reflected that there is a conflict of interest, and she had not informed patients that her brother runs the centre or that she receives kickbacks.

Repeated preferential signposting could undermine patient trust and is considered unethical in the Malaysian Medical Council (MMC) Code of Professional Conduct. It is also clearly stated in the MMC’s Code of Professional Conduct that a practitioner must not practice fee-splitting or any kickback arrangement as an inducement to refer or receive a patient from another practitioner, institution, organisation or individual. [https://mmc.gov.my/wp-content/uploads/2022/04/Code-of-Professional-Conduct-2019.pdf]

Professionalism

While ‘professionalism’ may seem straightforward in theory, applying it in practice can be far more complicated. Many calls to the Medical Protection advice line involve clinicians seeking guidance on situations where professional boundaries are at risk of becoming blurred or have already.

Most clinicians will be aware of their day-to-day professional obligations to their patients and colleagues and the core principles and values that the MMC require adherence to in the Code of Professional Conduct.

These obligations include:
·       Maintain their knowledge and skills
·       Act with honesty and integrity
·       Treat patients and colleagues fairly
·       Maintain professional boundaries.

Probity is also a key area, concerning honesty, integrity and trustworthiness. It is central to the public trust placed on the medical profession.

Most clinicians never intentionally aim to bring the profession into disrepute or undermine public confidence in it. However, increasing pressures both inside and outside the workplace can mean boundaries are forgotten or become blurred. When this happens, doctors can find themselves at the centre of a regulatory or disciplinary process.

Medical professionals who work independently for example, in private practice or as a single-handed general practitioner (GP), may find themselves more vulnerable due to a lack of informal safeguards. Having people around them can often help to enforce the importance of clinical and social boundaries. Those working under extreme pressure or in emotionally charged clinical situations may also find it difficult in the heat of the moment to remember their professional responsibilities towards their colleagues or patients.

It is important to remember the significance of role modelling when considering professionalism. How a senior clinician addresses a patient or staff member during a consultation can have a considerable impact on those observing their actions. Whilst treating patients with respect and without prejudice may seem an obvious example of professionalism, it can be easy to forget that off-the-cuff comments made during a coffee break or on a WhatsApp group could be deemed as unprofessional by a regulating body.

Often it is the actions of a clinician outside of the work arena that result in concerns or complaints being raised with the regulator. Emotive reactions to political or social situations on social media, interactions with patients when ‘off duty’ are but a few examples that can result in a referral to the MMC.

The above are all examples of where a clinician’s actions or behaviour in that given circumstance have resulted in a case before the regulator for undermining public confidence in the profession.

It can often appear unfair that the actions of a doctor away from the work environment are still held to account, where in other professions this may not be the case. However, conversely some may see professionalism as a contract that healthcare professionals should always fulfil with the reward being the trust of their patients and the respect of the public.

It is important to remember that being professional isn’t about trying to remember or learn the contents of the Code of Professional Conduct. It is about medical professionals familiarising themselves with the key concepts and applying the standards that are relevant to the individual’s knowledge, skills and experience when followed in context.

Rather than focusing on rules and standards, it is important for a medical professional to obtain the skills to be able to take a step back and think through a situation calmly whilst being able to communicate clearly and professionally. This can take skill and strength but getting it right can protect both patients and clinicians.

Continued learning

Ongoing learning can help HCPs to recognise those ‘grey’ moments before they become a problem.

Medical Protection members can access the Professionalism course on The Learning Hub at no extra charge, as a benefit of membership. This interactive online course looks at how small, everyday behaviours can affect trust, consent and professional relationships, and why boundary issues often arise unintentionally. It also acknowledges the reality of modern practice—social media, cultural differences, global patient expectations, and working across teams and settings.