How best to set the ways we communicate with each other, and so to establish our “rules of engagement”, can be difficult’. Moreover, any “rules” we establish may vary over time, either in the long term (plenty of doctors who meet in the work place later marry), or more acutely if circumstances change (one moment I may be talking to a neighbour as a friend and then seconds later, and in the event of a medical emergency, as a doctor). Nevertheless there are rules, and as a doctor/academic, an overriding principle requires us to treat patients/colleagues/students in a professional manner, ie to have a relationship that is professional. At its simplest, professional relationships are those relating to work, and where work goals are agreed and given priority (in a setting ultimately determined by the employer); where solutions are achieved through negotiation and in an atmosphere of mutual respect, where the business at hand is dealt with rationally and dispassionately; and where there is a requirement for accountability. When the work involves dealing directly with people, there must be respect and politeness, and if this extends to patients, there must also be kindness, empathy and the notion of caring. The arrangements when working alone, (for example, from home, linked electronically) will clearly be different again.
How very different these relationships are from those which are personal/private. Almost by definition these occur outside the work place proper, and because of their very nature are likely to based on a person’s whims or circumstances, for which the persons alone are responsible, and in which there is an element of choice. Such relationships include levels of warmth, privacy, and emotion, linked with sentiments such as liking, disliking, loving, infatuation, intimacy, jealousy, hatred, and of course, ambivalence. With these feelings will come views reflecting, for instance, prejudice, infatuation and favouritism, and behaviour that might be controlling, bullying, stifling etc.
It is my view that despite the clear distinction between the two approaches, when doctors interact with patients, colleagues, or students, it is common for them to confuse, or even to be unaware of, the two alternatives. Consequently, there is often a failure of doctors to recognise how they bring their personal/private ‘baggage’ into the professional relationship. Ultimately, a relationship established in the wrong category can, and all too often does, lead to confusion, mismanagement, and even abuse.
It is in their relationships with patients that the failure of doctors must be the most unacceptable in societal terms. In my view, it is because some doctors incorporate their personal baggage into professional relationships that they find it difficult to communicate with black or minority ethnic patients; can’t hear when women complain of certain symptoms; feel awkward with patients who are gay or lesbian, let alone those who are transsexual; find patients who self-abuse distasteful; get exasperated by obese patients who will not lose weight or asthmatics who continue to smoke; distrust patients with certain accents (how the ‘Irish’ have suffered this) or social status (working class patients generally get a very bad deal), and finally get angry with patients who do not ‘comply’ with treatment. And, of course, there are those ‘heart sink’ patients where issues combine to make the doctor feel helpless. Surely such cases would never arise in relationships that were truly professional.
Like any one else, I have liked/disliked some patients more than others, but as soon as I became aware of it entering into, and possibly interfering with, my professional relationship, I would try to resolve the issue through self reflection or by talking the issue through with a confidant. Although completely avoiding personal/ private relationships with patients is difficult, if not impossible, the more we know about ourselves, the easier avoidance becomes.
Turning to relationships with work colleagues (seniors, juniors and peers, alike), it is my view that problems are so widespread that we are probably talking in terms of an epidemic. Interestingly, having personal rather than professional relationships spawns both excesses and omissions. It is the excesses that lead to, and can be the only reasonable explanation for, bullying (for which surgeons are infamous but by no means hold a monopoly), threatening or belittling behaviour, teasing, coercion, bribery (classically in relationships with industry), and sycophancy (towards those in power). It can also often play an important part in acts of favouritism (asking particular juniors to give lectures, attend meetings), exclusion (from committees for instance), and patronage generally. Omissions are manifest when a doctor is unable or unwilling to criticise the behaviour of black or minority ethnic colleagues for underperforming (so, if nothing else, denying them the opportunity to improve), when a junior is unable to challenge senior members of staff when their views or actions are clearly questionable, when a senior doctor seems unable to hear what more junior staff are saying when they have legitimate complaints (a common enough problem for whistleblowers!).
The final, and for me the most difficult, is the relationship struck with students, where problems arise particularly when working closely with individual students over a prolonged period (say, when acting as a BSc tutor and ‘working’ with a student for 2-days a week for a term, or with problem-based learning groups for 6 hours a week for two months, or for 2 hours a week for a year), or when acting as a personal tutor when matters private to the student almost inevitably arise. As teachers, we are educators, advisors, in some ways act in loco parentis, and sometimes serve as role models. In any formal setting the aim (and the one to which I have aspired) is to have professional relationships and so treat all students dispassionately, as ‘equal’ to one another, and to ensure that none is ignored and none favoured. However, for me, slippage into a more personal relationship can (and does) arise in areas outside the teaching arena (in the corridor, over a coffee, at the end-of-term tutor group dinner or other social venues, when giving a present to a student who becomes a parent etc). The balance here between the personal and the professional is difficult and the fact that I continue to know and meet some students after they have qualified (I was delighted to be invited to the weddings of two such in the last few months) is evidence that in many respects the relationship can, and sometimes does, move across the boundary (as of course occurs sometimes with work colleagues). While I find teaching very fulfilling, it is this very ambiguity that makes for concern, and one that I am still unable to resolve to my satisfaction.
Increasingly, doctors are made aware that communication is a crucial component of a successful career. Key components of communication such as empathy, sympathy, listening, repeating, respecting etc are one thing. Muddling the personal/professional paradigm is another, and in my view one in which there is still much to be done.
Joe Collier is emeritus professor of medicines policy at St George’s, University of London