Care in the community
Treating those close to you in rural communities means following a different set of guidelines
Doctors are discouraged from treating those close to them, but there are exceptions to this general rule. The Medical Council’s Statement on Providing Care to Yourself and Those Close to You allows doctors to treat those close to them “if the doctor works in a small community where there are people close to them who are patients because of access issues”.
“This type of situation applies to doctors in places like Bulls, somewhere in the West Coast, or in little towns around New Zealand,” says Dr Tim Cookson, MPS medicolegal consultant in New Zealand.
Limited choice in the rural setting
In rural communities, there is increasing remoteness and isolation – rural dwellers may have little choice in which health services to access1, and rural doctors may have little choice about who they treat.
In New Zealand, approximately 14% of the population is reported to reside in rural areas.2 In places like the Chatham Islands, the doctor has no choice but to treat family members and close friends.
When a family member or close friend is injured or sick, the doctor needs to make some treatment decisions. In an emergency, the doctor needs to get on with it. “In an area with two to three doctors, you have more choices as someone is close by who can do it,” says Ron James, a doctor in Wairoa. “It’s quite clear. If there’s more than one doctor, don’t treat a family member. Treat family only if it’s a minor issue.”
Relationships and setting boundaries
With remoteness, doctors may be put in situations they normally wouldn’t find themselves in and they will need to set clear boundaries. Establishing clear boundaries will involve careful negotiation as the GP moves in and out of professional versus personal relationships.3
“Your patients are the people who repair your roof and pack your groceries,” says Ron James. “I have a number of patients who are some of our close friends in town. It’s about recognising boundaries and that it’s different from the urban situation, where you live in one place and work in another.”
A rural doctor may socialise with patients, may know everybody they treat, or they may have grown up in the area – which can make maintaining professional boundaries difficult. Foreign doctors can be particularly vulnerable, as they are building social networks alongside professional relationships. “It’s certainly a bit of a challenge,” says Richard Simpson, who was in solo practice in Cheviot, North Canterbury, for ten years after emigrating from South Africa.
“When I came here, everyone I met was a stranger. I knew them as patients first, then friendships developed, but I was able to maintain professional relationships in the surgery. I now practise in Milton and live in Dunedin. It’s quite different: I don’t socialise with patients now.”
Case example
A doctor diagnosed his partner with depression, failed to keep records of consultations and prescribed an antidepressant. The Health Practitioners Disciplinary Tribunal found the doctor guilty of professional misconduct and considered that had the doctor been truly objective, he would have realised he could not be involved in his partner’s care, given the complexity of the issues she was facing.
- Think about the long-term consequences. “The particular issue in rural medicine in New Zealand and Australia is the limitation of choice,” says Campbell Murdoch, Winthrop Professor of Rural and Remote Medicine, Rural Clinical School of Western Australia.
“When it comes to family members, the practitioner is obviously keen to get the best possible medical care for their family. The real problem is the borderline between what you could do and what you should do. It’s quite simple. Ask yourself: ‘I am going to take a certain course of action. Are there any long-term consequences of what I am about to do?’ In this context, issues can be addressed.”
- Set clear boundaries. This can be a challenge. Rob Henderson, a doctor in Invercargill who researched experiences of rural doctors, says: “Sometimes patients had difficulty understanding boundaries and doctors often weren’t prepared for it.” His research found that “friends are usually patients and patients are usually friends, which makes it difficult to define social patient boundaries”,4 and that doctors had to learn various strategies to meet the community’s expectations of them, and also maintain a tolerable patient/friendship balance”.5
Guidance for rural doctors
Be aware of how you feel, use judgment and common sense, and ask yourself in each situation if it is appropriate to treat a family member or friend. “It’s hard to think it will ever be acceptable for a family member to be getting ongoing treatment for a mental illness,” says Ron Paterson.
Views
MPS
“We recommend the Medical Council policy and understand that doctors can depart from these policies for various reasons,” says Tim. “We can provide initial advice on the phone from a medicolegal consultant and we have very experienced barristers available to assist with any problems that might arise.”
Health and Disability Commissioner
“The same reasons that make it unwise for a doctor to treat family members or close friends apply in a rural or urban setting,” says Ron Paterson, Health and Disability Commissioner.
“The reason is the same – the risk that one’s judgment may be clouded. “There are rural communities where it’s not that difficult to have alternative care, but in a very isolated community it can be very difficult. Where situations like this arise, I’d get guidance from the Medical Council, a wise peer, and take into account the Code of Health and Disability Services Consumers’ Rights.
“In rural settings, there are few complaints about providing care for family members.”
New Zealand Rural General Practice Network
“A growing trend for rural practitioners now, in all disciplines, is to seek an outside professional for care of their families,” says Kirsty Murrell-McMillan, Chairperson, New Zealand Rural General Practice Network.
“However, in isolated communities where the practitioner is a member, I think that treating family members and the community is sometimes unavoidable. We’ve put careful boundaries around this and we work closely with the Royal New Zealand College of GPs and the Medical Council. We encourage GPs to seek supervision and counselling on their feelings and to identify the ethical issues of dealing with these patients.”
The author, Rosalie Chamberlain, is a freelance writer in New Zealand.
References
1. Ross J, Rural Nursing, Aspects of Practice, New Zealand Rural Health Opportunities, Ministry of Health (2008).
2. Fraser J, Rural Health: A Literature Review for the National Health Committee, New Zealand Health Services Research Centre (2006).
3. Burton J, Rural Health Care in New Zealand: RNZCGP Recommendations; Occasional Paper Number 4, RNZCGP Rural Representative (1999).
4. Henderson R, Why Doctors Leave Rural Practice: A Qualitative Study Examining the Problems of Rural Practice, thesis submitted to University of Otago, Dunedin (1999).
5. Henderson R, Complaints Against Rural Doctors: The Impacts on the Quality of Rural Health Care Services and on Rural Communities, thesis submitted to Massey University, Palmerston North (2003).