This is the second in a six-part series on general practice ethics. Cases from practice are used to trigger reflection on common ethical issues where the best course of action may not immediately be apparent. The case presented in this article is an illustrative compilation and is not based on specific individuals. The authors have provided a suggested framework for considering the ethical issues to allow practitioners to come to an ethically based conclusion.
Dr Brian has been caring for the Lucas family for more than 10 years. John and Mary’s son, Jimmy, is 4 years of age and was recently diagnosed with symptomatic diabetes mellitus. This led to considerable stress on his parents. John and Mary needed a lot of support and encouragement through the diagnostic process as Jimmy was established on insulin treatment.
Dr Brian’s clinic has a message system (telephone and email) in place for patients to use; messages are screened by the practice receptionists. However, Dr Brian gave John and Mary his private mobile phone number in view of their anxiety and the clinical situation. He encouraged them to call him with any problems as Jimmy was stabilised on treatment. He stressed that the mobile number should only be used for questions about Jimmy’s diabetes until they felt more confident in managing his care.
Initially, John and Mary visited the clinic twice a week. They called Dr Brian on his mobile phone only a few times, mostly for minor queries. Jimmy started to feel well. His blood glucose levels were improving, but had not yet reached the target set by his diabetes specialist.
One morning, on his day off, Dr Brian received a text message from Mary on his mobile phone. Mary asked for his ‘urgent help’ in arranging a referral to another diabetes specialist.
Should Dr Brian immediately respond to the message? If so, how? What should he tell Mary about the use of his private phone number?
What are the ethical issues?
This case raises questions about the impact of using technology (eg mobile phones) as a means of communication in the doctor–patient relationship, and the boundaries of that relationship. We focus on questions that are relevant for virtual communication:
- How are the duties and responsibilities of the general practitioner (GP) affected by using virtual modes of communication?
- What kinds of limits should GPs place on their availability, and how are these limits affected by mobile phones?
- What duties do GPs have regarding requests that are perceived to be ‘urgent’ by patients?
The patient’s perspective
Mary was very pleased when Dr Brian gave his private mobile number to her. This allowed her to contact him immediately when she was concerned about Jimmy’s treatment, instead of relying on the message system at the practice, which can be slow. She felt that Dr Brian trusted her. Using a text message instead of making an appointment is faster and more convenient from her point of view, especially if she wants a quick reply. She could also give the number to her mother, which would reduce her mother’s anxiety about minding Jimmy, now that he has diabetes.
It might seem ideal to Mary, but communicating by text messages may not be in her best interests if important information is not shared or important actions are omitted.1 Dr Brian will not be able to see Mary’s body language, have a conversation with Jimmy or see other clinical cues visible in face-to-face medical encounters. Text messaging exacerbates these problems as the patient’s voice and affect cannot be observed. Further problems might result, given the limits of text messaging, including potentially significant misunderstandings. For example, lack of punctuation can create ambiguous messages, widely used abbreviations may be misunderstood and messages may be misinterpreted. These drawbacks may not be obvious to Mary, who might be disappointed if Dr Brian does not respond in the immediate way expected of messaging.
The GP’s obligations and duties
Dr Brian provided his private mobile number to John and Mary because he saw how distressed they were with Jimmy’s diagnosis. He wanted to ensure that any problems in Jimmy’s care were quickly addressed, and that John and Mary felt fully supported as they managed his diabetes. Despite his beneficent intent, his actions may have unintended consequences.
Electronic communication changes the dynamics between GPs and their patients. GPs listen to all of the patient’s concerns, explore unvoiced concerns and respond appropriately during face-to-face consultations. However, these duties are less clear with other modes of communication. Time constraints make it impossible for each text message sent by a patient to trigger a full virtual consultation.
The request might seem simple in this case, but Dr Brian has two concerns. First, he is uncertain about the reason for the urgent request. It might reflect a deterioration in Jimmy’s condition, which would require immediate attention. Alternatively, Mary might have just found it more convenient to use the private number rather than make a clinic appointment.
The second concern is limiting the demands on Dr Brian. Giving Mary his phone number allowed her to contact him at any time. This kind of access may be warranted in specific situations (eg palliative care). Some GPs may feel greater access improves the quality of care they offer, which makes them feel helpful and in control. However, this can come at a cost. Disturbances to the GP’s private life can cause stress, trigger feelings of invasiveness, increase burnout and have adverse effects on the doctor’s health and wellbeing.2
There are questions about the impact of text messages and other forms of virtual communication on the boundaries of the doctor–patient relationship. The informal, immediate and sometimes ambiguous or intimate nature of text messaging alters the tenor of the relationship, which can potentially cross that boundary. Text messages relating to specific aspects of patient care may be effective in patient management and be valued by the GP and patient. However, crossing an apparently trivial boundary can quickly escalate into more serious boundary violations, threatening patients and physicians.3,4
Finally, virtual communication raises issues of confidentiality and fidelity.5 Doctors must follow simple rules when using these forms of communication, including not revealing private information through unsecured media, and ensuring that patients do receive intended text messages.
Potential actions and consequences
Dr Brian’s options are to respond immediately (eg text, calling or asking his practice staff to contact Mary) or when he returns to work. He can fulfil the request for a referral without meeting Mary or ask her to make an appointment. Dr Brian’s duty of care to Jimmy (after all, there may be an emergency), and the expectations created by giving Mary his mobile number suggest he should respond immediately rather than wait until he is back on duty. Texting her to make an appointment for the next morning will meet the expectations of immediacy engendered by this form of communication, while reinforcing the importance of face-to-face consultations. An immediate response preserves the doctor–patient relationship without leaving Mary feeling abandoned.
Dr Brian is starting to set limits by insisting on an appointment rather than acceding to her request by text. It will be important for him in the next consultation to follow up with further discussion about when it is appropriate to contact him on his mobile phone.
Virtual forms of communication (eg texting) can support patients and may contribute to better care. However, these informal communication methods may intrude on the doctor’s leisure time and undermine standards of care if they replace face-to-face consultations.
Texting may cross boundaries in potentially unprofessional ways, especially when particular patients are favoured with this privilege. It may disadvantage patients who are not favoured or who are not comfortable using mobile technology. We also note that GPs cannot control the distribution of their number or recall it without the inconvenience of changing the number once it has been disclosed.
Virtual communication is an integral part of the way we live, despite the potential pitfalls. Each form (social media, electronic messaging systems, video consultations, mobile phones, etc) has its advantages and disadvantages. This makes it important for practices to develop policies supporting the responsible use of virtual communication. Such policies should:
- clarify (for patients and GPs) when its use is appropriate
- accommodate doctors’ individual preferences regarding technology
- provide guidance regarding GPs’ duties, especially for interactions that do not allow full evaluation of patients.
GPs may wish to have specific criteria for providing patients with this degree of access, set very clear indications and contraindications to its use, explain the potential pitfalls, and ensure that text messages augment good care rather than replace it.
Yishai Mintzker MD, Clinical Instructor, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Wendy Rogers BMBS, BA (Hons), PhD, MRCGP, FRACGP, Professor of Clinical Ethics, and ARC Future Fellow, Department of Philosophy and Department of Clinical Medicine, Macquarie University, Sydney, NSW. email@example.com
Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.
- Derse AR, Miller TE. Net effect: professional and ethical challenges of medicine online. Camb Q Healthc Ethics 2008;17:453–64.
- Miedema B, Easley J, Fortin P, Hamilton R, Tatemichi S. Crossing boundaries: Family physicians’ struggles to protect their private lives. Can Fam Physician 2009;55:286–87.e5.
- Bird S. Managing professional boundaries. Aust Fam Physician 2013;42:666–68.
- Galletly CA. Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation. Med J Aust 2004;181:380–83.
- Farnan JM, Snyder Sulmasy L, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM. Online medical professionalism: Patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med 2013;158:620–27.