Appendix C. Case studies

Dr Xiong is specialist trained, younger doctor who has adapted well to working in general practice. You have observed his consulting and you find that he has some minor knowledge deficiencies. His clinical skills are of a good standard. The reception staff report to you that patients have been complaining of difficulty understanding him and they are reluctant to see him again. From your interactions with him, you have noticed that he has an accent but by paying close attention you were able to understand what he was saying.

Is there anything else about Dr Xiong’s consulting that you would like to know?

It is important to obtain a clearer understanding of the patient complaints. There are many possible explanations for why patients might be reluctant to rebook with Dr Xiong. Is language the problem (eg accent, language skills) or is it communication skills instead? The issue may be his consulting skills; however, are patients putting it down to an issue of ‘language’ or ‘culture’? Has anyone else, besides patients, had difficulty understanding Dr Xiong? Could it be that the reception staff do not relate well to Dr Xiong and/or have difficulty communicating or interacting with him?

What kinds of things contribute to difficulties with communication?

There are several factors that may contribute to communication difficulties:

• ineffective communication skills, including body language and attention to verbal and non-verbal cues
• language (eg vocabulary, sentence structure, idiom)
• pronunciation, accent and intonation
• a doctor-centred approach.

Are there any other issues that should be considered?

Other issues to consider:

• prejudice on the part of staff/patients
• patients who are difficult to understand for the same reasons as the doctor (eg accent, pronunciation, idiom).

What are the obstacles to improving language skills?

Obstacles include:

• not devoting time to practising language skills
• unwillingness or inability to change.

Dr Goran is an older doctor who passed the written segments of the Fellowship exam (AKT and KFP). He has, however, failed the clinical segment (OSCE) by a significant margin.

How might you explain this?

There are several possible explanations:

• overconfidence – he may believe, or others may have told him, that he has good clinical skills and that he shouldn’t have any difficulty passing (and he therefore did not study)
• inadequate preparation for the exam (eg too busy to study, not dedicating sufficient time to study, not prioritising exam preparation time, learning cases off by heart and not actually role-playing them, not role-playing to time, not being critical enough with each other in the study group, inability to connect with a study group)
• professional isolation
• unfamiliarity with exam requirements.

Dr Goran is quite upset by his result. He says that he didn’t find the cases difficult. He ran out of time with several cases and consequently was unable to address management adequately. You understand how this might have happened because you have observed him in his consulting and his style is very considered. You believe that he has good clinical skills, however, because of his style, his consultations are invariably long.

How can you assist Dr Goran so that he doesn’t have the same problem when he next sits the exam?

• It would be useful to review his consulting skills, even though you may have observed him previously. Certain approaches or habits in the consulting room may not work so well in the exam room where time is limited. There may be something about his consulting skills that you haven’t considered, and which is contributing to his slowness.
• Useful strategies as practice for the exam include:
  • Role-play a variety of scenarios with an emphasis on efficiency and time management. Provide him with a framework or some useful tips that he can also practise in the consulting room.
  • Video-record some of the role-playing so that he may gain insight into his strengths and weaknesses.

Dr Alexei is an older doctor who passed the written segments of the Fellowship exam (AKT and KFP). He has, however, failed the clinical segment (OSCE) by a significant margin. You have observed him in consultations and you believe that he has good clinical skills. You have noticed that he tends to be nervous when he is being observed and makes simple mistakes (forgetting something that the patient has said, being distracted by the computer, having to stop and think frequently). His nervousness is worse when doing exam practice, to the point that the consultation becomes unstructured and he runs out of time.

How can you know that it is only his nervousness that is responsible for his failure?

The fact that his consulting deteriorates even further during role-play suggests that it is his nervousness. Case discussion would be a simple way of deciding whether there are any clinical skills concerns that also need to be addressed.

How can you assist Dr Alexei with his performance anxiety?

Dr Alexei’s performance anxiety is not something that will be managed solely with simple strategies that he can implement during the exam. Similarly, ‘quick-fix’ measures just before the exam (such as taking a sleeping tablet the night before or an anxiolytic on the day of the exam) will not help. This is a bigger problem that Dr Alexei must address for himself. You can assist him by highlighting the importance of seeking help and seeking it early. He should discuss his problem with his GP and referral to a psychologist would be beneficial.

Dr Uma failed the AKT and KFP exam on her first attempt, despite being very capable clinically. She admits that she didn’t study as much as she might have because she thought that she would pass. She says that she has already put together a study plan and will be working on this diligently.

How can you assist her with her preparations for the next exam?

You remind her of the importance of addressing areas of knowledge deficit, including patient presentations that she is not seeing or that she is not very practised at. She can also reflect on the topic areas in the paper that she found more difficult and put those on her learning plan.

Is there anything else that you can do?

You can observe her in her consulting and appraise her consulting skills.

You have never observed Dr Uma in her consulting. Your basis for believing that she has good clinical skills is from the regular case discussion that you have been conducting with her and also from reviewing her clinical notes. You decide to observe her in her consulting and you confirm that she has good clinical skills; however, you notice that Dr Uma has a habit of frequently consulting online resources for things that you expected she would have committed to memory, such as doses of frequently prescribed medications and common disease guidelines. Dr Uma explains that she doesn’t bother with remembering things that she can easily look up.

Does this observation matter when it is impossible for anyone to commit everything to memory?

There is nothing wrong with using online resources in the consultation. Dr Uma does it very efficiently and without undue disruption to the flow of the consultation. For the exam, however, certain facts have to be committed to memory. It is also important to have experience in managing a broad range of clinical presentations because information that is used frequently will be retained and then recalled more readily. Dr Uma has not considered that this might work against her in the exam.

For some GPs, it may have been many years since they have had to plan and engage in substantial study. Life events, financial imperatives and work pressures may also compete for their time more than in previous years. It may therefore take more time and they may require extra support to get into a studying frame, to dedicate time for study and to improve the quality of their study time.

In addition, as GPs become more experienced clinically, they develop efficiencies of practice that become habit. They generally also have well-developed problem-solving skills. Consequently, they may find it difficult to explain why they do what they do. Older, more experienced doctors may also find it difficult to go back to a style of practice that students and trainees are expected to demonstrate in an exam. It is not unusual for them to fail a knowledge test (because their knowledge base is not at the expected level for the exam) or even to fail an OSCE exam (because of not paying attention to exam technique).

Dr Anwar passed the AKT quite comfortably but failed the KFP by a very small margin. You know him to be quite capable clinically. He admits that he didn’t study as much as he should have. He was very confident about his knowledge base and while he did have a study group, he didn’t participate in the group activities very often. He admits also that his home study was interrupted because after coming home from work, he would play with his toddler son.

How can you assist him with his preparations for the next exam?

Dr Anwar may have been overconfident about his abilities and therefore did not pay as much attention to study as he might have. Competing priorities (eg family time and responsibilities, other pressures) can make it very difficult when it comes to allocating study time and also studying effectively. Some of these competing pressures can be readily addressed; however, there are situations, such as illness and difficult family circumstances, that aren’t easily addressed. Nevertheless, realistic options for managing the situation at hand and enabling regular, dedicated study time should be considered. Even with the most difficult of situations, simple measures and supports can be of great benefit. Sometimes, the better option may be to defer sitting the exam.

Dr Navid has failed the AKT and KFP, both for the second time. He is distressed because, in his own words, he was ‘very close to passing this time’. His results are as follows (pass mark in brackets).

What do you say to him? 

Dr Navid’s scores are all well below the pass mark and he needs to recognise this. On face value, his scores indicate significant knowledge deficits and significant difficulty with clinical reasoning. The fact that Dr Navid believes that his second set of results were ‘very close to passing’ suggests that he lacks insight into what is required to pass the written exams.

Could his poor scores be due to poor exam technique?

While difficulties with exam technique (especially with the KFP) can certainly be contributory, Dr Navid’s scores cannot be explained by that alone.

How can you assist him with his preparations for the next exam?

A good question to ask Dr Navid is, ‘What exactly do you do when you are studying?’ It may be that he is passively reading texts and magazine articles rather than identifying and prioritising deficit areas and actively working on them. He may not be aware of the scope of general practice and consequently unaware of what knowledge and skills he is expected to have. In fact, there are many possible reasons for Dr Navid’s failure to pass. All these need to be explored and a study plan drawn up (refer to Appendix B).

Dr Navid says that he will defer the exam for six months so that he can apply himself diligently to the learning plan. Twelve months later, he reports to you, once again very distressed, that he has not passed. He says that he has been studying, much more than with his previous attempts, and he cannot understand why he has failed again. He believes that there has been an error with the marking of his papers and he wants to appeal. His scores are as follows (pass mark in brackets).
 

How do you respond to him?

Dr Navid has the right to appeal if he wishes; however, his scores are still significantly below the pass scores and it is unlikely that this would be due to an error in marking.

How do you explain the fact that his scores are still significantly below the pass score?

There are several possible reasons:

• not studying enough
• not studying effectively
• not adhering to what was recommended in the study plan
• not having someone more experienced to guide him
• working in a limited scope of practice (ie limited exposure to a variety of patient presentations and therefore limited opportunities to gain experience and apply what is learnt)
• lacking insight.

It may be that Dr Navid does not have the abilities, not just to study and pass the exams, but more particularly, the capabilities required of a GP in order to practise safely and independently.
 

Dr Yin Chan passed the written segments of the RACGP exam after three sittings (comfortable pass in the AKT, just over the pass score in the KFP). She is very upset because she failed the OSCE. She believes that she should have passed because, in her own words, ‘I got the diagnosis in just about all of the cases’.

How do you respond to her statement?

While she may well have been able to make a diagnosis in most cases, marks are not allotted for this alone. In some cases, it may not be possible to confirm a particular diagnosis and instead, the candidate is expected to formulate a short list of appropriate differentials or a working hypothesis. Candidates are also expected to manage the patient holistically, using a range of clinical skills. Marks are allocated according to how well the appropriate skills are used in each case.

What might be the reasons for her failure?

There are many possible reasons, including:

• unfamiliarity with what is expected of candidates in the OSCE exam, hence the belief that it is the diagnosis that matters (refer to: RACGP Education: Examinations guide for further information on each exam segment, including format, preparation, development, standard setting and results)
• inadequate preparation (eg not engaging in role-play of cases; how the role-play was conducted, such as not being critical enough with each other in the study group; learning cases off by heart; role-playing to script)
• having a formulaic approach and consequently not thinking about the information, not responding to patient cues, providing information and delivering a management plan that is not tailored to the individual.

How can you assist her with her preparations for the next exam?

• Consider the range of clinical presentations that she is exposed to. What is she lacking in experience?
• Observe her in her consulting – it is important to have a sense of what her consulting skills are like in the real situation. If direct observation is not possible, review of video-recorded consultations is an option. An alternative option would be to role-play two to three clinical scenarios (not as exam cases but as she normally would in her consulting). Weak clinical skills or a poorly considered approach to the patient will certainly translate into poor exam performance.
• Exam practice – role-play a variety of scenarios with an emphasis on process, effectively using the necessary skills, responding to the patient and tailoring management. What she learns from the role-play she can also practise in the consulting room so that it becomes habit. Role-play of presentations that she is not familiar with will also be beneficial.

 

Dr Thwe completed her first 12 months of general practice training and during that time no serious concerns were raised regarding her clinical skills. She then took time off because of various family commitments and returned to training 18 months later. Not long into her current term, her supervisor raises some serious concerns about her clinical performance. He says that Dr Thwe’s skills have regressed and that she is performing at the standard of a medical student (ie she is able to gather information and conduct a basic physical examination but has difficulty formulating a diagnosis and appropriate management plan).

The specific concerns are that Dr Thwe:

• asks questions regarding every patient that she sees – often about things she would be expected to know and frequently the same questions
• will sometimes get an opinion from another doctor in the clinic even after already having been told what to do by her supervisor
• appears unable to assess risk in some consultations and has consequently made some significant errors. One example: an elderly patient saw Dr Thwe because of rectal bleeding. Dr Thwe failed to adequately assess the patient and sent him home. The next day, the patient returned to see another doctor and had to be urgently admitted to hospital.

What is going on here?

There are several possibilities as to why Dr Thwe’s skills have regressed. For example, it may be that she has a personal health problem or there may be serious issues at home that are causing her to be stressed or distracted. It may also be that Dr Thwe didn’t have very strong skills in the first place. For example, she may have been in more supportive working environments previously, or perhaps she was only seeing straightforward presentations and wasn’t having to manage more serious presentations as she is now.

What should happen now?

It is important to communicate the concerns with Dr Thwe and ask for her perspective.

Dr Thwe acknowledges that she is struggling and confides that she has been going through a difficult time. She says that she took time off because she didn’t have anyone to look after her child when her mother had to return suddenly to her home country. She has been forced to return to work because her husband is now unemployed. She is finding it difficult to look after her child, manage her home responsibilities, work and study.

What else should happen?

It is important to get a better sense of what Dr Thwe’s consulting skills are like and direct observation would be the preferred method.

It sounds like Dr Thwe requires more support at home and she should be encouraged to consider realistic options for addressing the situation. It is also important for Dr Thwe to address self-care (ie the various stresses and her mental state). She should be encouraged to seek help from her own GP and other health providers as appropriate.

Following direct observation of Dr Alina, you provide her with feedback and inform her that there are some aspects of her consulting that could be improved. You noted that with every consultation:

• there was poor structure to the consultation (ie moving back and forth between history and management very frequently)
• she conducted minimal physical examination
• she was hesitant in the formulation of her management plan (as if she wasn’t sure what to do)
• the management plan was delivered in a disorganised fashion and the patient appeared confused about what to do.

Dr Alina acknowledges that she is having difficulty. She says that more often than not she is unsure whether she has made the right diagnosis and consequently she goes back to check information. She also says that her patients interrupt her by asking questions and she loses track of what she is doing because she is compelled to respond to them.

How can you assist Dr Alina to improve?

You tell her that from your observation, she might have more surety as to the diagnosis if she takes a better history and conducts an appropriate physical examination; consequently, the required management will be much clearer. Patient questions can generally be left to the end of the consultation. This will assist with maintaining her focus and the flow, and it will probably be easier to answer questions at the end when she has a better sense of the problems at hand.

In consultation with Dr Alina, you prepare a learning plan that will address the concerns and strengthen her skills.

What should be included in the learning plan?

It is important that all issues are itemised on the plan, including how they will be addressed, what resources will be required and the expected outcomes. It is also important to specify a time frame for the plan and what form of assessment will be conducted, upon its completion, to determine whether the outcomes have been achieved. Other important elements to include in the plan are what her supervisor’s role will be (if her supervisor is able and willing to assist), and whether Dr Alina might benefit from the assistance of a medical educator and/or mentor (and what their roles will entail).

Learning plans should be realistic and any constraints should be taken into consideration (refer to the RACGP Practice Experience Program (PEP): Remediator guide, which provides information with respect to remedial assistance that is available to GPs enrolled in the PEP).

Dr Alina should also spend some time sitting in on her supervisor’s or other GPs’ consultations so she may gain a better understanding of what competent experienced general practice is and what she should be aiming for.

As agreed, you return to conduct direct observation of her consulting and to determine what progress has been made. You are pleased to see that her consulting has improved considerably and is now of an acceptable standard. You encourage her accordingly.

You return six months later to conduct direct observation of her consulting. You observe a significant deterioration in her skills. In fact, all the original concerns have reappeared.  

What might account for this?

Dr Alina’s skills may have regressed because of one or a combination of the following:

• a heavy workload resulting in shorter consultation times (and the learnt skills are not maintained because they haven’t become habit)
• not seeing any value in adhering to the learnt skills (‘it takes too long’)
• something may be happening in her personal life that has caused her to be distracted from doing her job properly (eg personal illness, family issues, financial problems).

How might you address this situation?

You inform Dr Alina that her consulting skills have regressed significantly and that they are now much as they were the very first time that you conducted direct observation. You ask her what the reasons for this might be.

Dr Alina says that she has had some health issues over the last few months. She has been diagnosed with diabetes and she has been feeling very tired because she has been finding it very difficult to manage her blood sugar levels. In addition, she has had one cold after another and, consequently, has had to take frequent days off work. She says that even though she may not be ‘doing it by the book’ as you want her to, she doesn’t think that there is anything wrong with her consulting because her patients are happy with her.

How do you respond to her?

You say to Dr Alina that even though her patients might say they are or appear to be happy with her, she has certain obligations towards them, as set out in the Medical Board document, Good medical practice: A code of conduct for doctors in Australia. This document sets out the principles that characterise good medical practice and it explicitly states the standards of care and professional conduct that are expected of doctors by their professional peers and the community. Failure to adhere to these principles (ie failure to do the right thing by her patients) may well result in an adverse event and/or a complaint about her to AHPRA. In order to be more explicit, you say to Dr Alina that her haphazard style of clinical work will result in poor outcomes for her patients because she is exposing herself to excessive risk by missing information, failing to identify serious conditions and failing to safety net or follow up her patients.

You also remind her that it is every doctor’s responsibility to attend to self-care and to ensure their safety to practise. This means that her personal health issues, family and other responsibilities have to be managed so that, as best as possible, they are not impacting negatively on her clinical capability and consequently compromising patient care. If there is potential for patient safety to be compromised, then time off to address those issues should be seriously considered.

As you are leaving, the practice manager takes you aside and says that Dr Alina has been taking a lot of time off and that this has been very disruptive to the running of the practice. She wonders whether Dr Alina has actually been ill because she has never produced a sickness certificate. She confides to you that she thinks that Dr Alina is lazy and asks you what the best thing to do with her is.

How do you respond to the practice manager?

It is not for you to comment on whether Dr Alina is or isn’t lazy and it is paramount that all parties maintain confidentiality in such situations. As for her taking frequent time off work and the matter of sickness certificates, that is an employment issue for the practice manager and the practice principle to address.

Dr Seyed sustained significant neck injuries in a motor vehicle accident. He was hospitalised for a short period and he took time off in order to recover. He returned to work and after a few weeks he reduced his working hours because he found that at the end of a full working day he was experiencing significant neck and shoulder pain. Two weeks later he decided to take time off because his pain had worsened and he wasn’t coping.

He returned to working after three months. The reception staff soon noticed that he often appeared vague or drowsy. Patients also complained that he wasn’t his usual self, he was overly focused on the computer and that he frequently asked them to repeat what they had said.

What might account for this?

There are several possibilities that might account for Dr Seyed’s behaviour. He may be:

• taking medication that is affecting his cognition
• under the influence of alcohol or illicit drugs
• significantly sleep deprived
• having difficulty managing his chronic pain
• under significant personal stresses that he is not coping with.

What should be done?

These observations cannot be ignored because they raise concerns about his safety as well as patient safety. It is important therefore to speak to Dr Seyed, as a matter of urgency, to inform him of what has been observed, to give him the opportunity to talk about what is going on and to offer him support. He should also be told that if the concerns are not addressed, he may be reported to the AHPRA under the mandatory reporting regulations.

Dr Yasmina comes to you to discuss a patient who is causing her distress. The patient, a middle-aged nurse, has chronic pain as a result of a motor vehicle accident several years ago. Her condition is now stable and the patient generally attends for repeat prescriptions for her narcotic analgesia. She never books appointments ahead of time, but rings and demands to be squeezed in when her medication is about to run out. When she arrives for her appointment, she is always rude to the reception staff, complaining loudly at having to wait. In the consultation she is condescending to Dr Yasmina and questions her medical knowledge. Dr Yasmina tries to behave professionally towards the patient. She is also concerned that the patient is taking an unnecessarily high dose of narcotic but every time she tries to address this, the patient badgers her and somehow convinces her to increase rather than decrease the dose.

Dr Yasmina says that in the clinic where she works, there are many patients, who are not her regular patients, who are also taking narcotic analgesia. She says that she feels pressured to re-prescribe that analgesia.

What are the issues here?

There are four issues:

1. The patient’s condescending manner towards Dr Yasmina is unacceptable and needs to be addressed.
2. The patient is, more than likely, drug dependent and is blocking Dr Yasmina’s attempt to address that problem.
3. Dr Yasmina lacks confidence or is not assertive enough to manage the patient’s behaviour.
4. Whether Dr Yasmina is supported by the practice and its policies with respect to managing such patients.

How can you assist Dr Yasmina?

Dr Yasmina needs to be more assertive with the patient; however, she needs someone to teach her how to do this appropriately (what to say and how to say it). Role-playing would be very helpful to practise assertiveness. Once she gains this confidence, she will be better able to manage the patient’s behaviour. She should be encouraged to have a discussion with the practice manager and principals about the difficulties she is having in managing demanding and abusive patients. The practice may need to consider an alert system or perhaps exclusion of certain patients from the clinic.

Dr Yasmina says that she has managed to convince some patients to reduce their narcotic dose or to prescribe what she believes is more appropriate. In such situations her colleagues have told her that she has no right to interfere with their treatment.

What can Dr Yasmina do?

Dr Yasmina has the right not to prescribe narcotics if she doesn’t feel comfortable about it. She can certainly advise patients about what she believes is more appropriate, but she should not be interfering with her colleagues’ management. She should refer the patients to their usual treating GP. She should also speak to her colleagues and tell them that she is not comfortable re-prescribing narcotics for their patients.

How can you assist her?

Once again, Dr Yasmina can be empowered to be more confident in stating her position.

This is also a matter that could be raised at the next clinical meeting.

Dr Ali is a colleague of yours working in the same clinic. It has come to your attention that Dr Ali’s note-keeping is very poor. Even when his notes are a little more substantial, his expression is often clumsy. You find this frustrating because it is difficult to know what has occurred in the consultation and what Dr Ali’s intentions were. You consequently have to resort to taking a history all over again, which the patients find annoying. While Dr Ali’s oral expression is sometimes ‘awkward’, you have not had any difficulties understanding him.

What are the issues here?

There are three possible issues:

1. Poor note-taking. Dr Ali may believe that it is not necessary to document much or he may not know what precisely should be documented.
2. Language difficulties. Dr Ali’s poor note-taking may reflect his English language skills. Difficulties with verbal communication (such as vocabulary and syntax) are often excused by the listener, especially when the speaker is able to convey their meaning. With the written word, the same difficulties cannot be compensated for as easily.
3. IT issues (eg poor computer skills, unfamiliarity with medical software, poor typing skills).

How to address the matter with Dr Ali

Good note-taking facilitates patient care. From reading the progress notes, it should be possible to know what transpired in the consultation and also the doctor’s reasoning (what the doctor did and why they did it) (refer to item 8.4 ‘Medical records’, in Good medical practice: A code of conduct for doctors in Australia).

Should you speak to Dr Ali about your concerns?

Most certainly. There is often reluctance to voice concerns, but if nothing is said, the situation will remain the same. You will continue to be frustrated by Dr Ali’s notes; Dr Ali will remain unaware that his notes are inadequate; and should a time come when Dr Ali might have to defend certain actions or decisions, his notes will not be supportive. Good notes are a doctor’s defence and the axiom to work by is: if it isn’t written down then it didn’t happen.

Why might some people not speak up?

There are several reasons:

• reluctance (eg it’s not my problem; they won’t listen; they won’t change)
• minimising the problem (eg we are all busy; it’s hard to keep good notes; he is not the only one who writes poor notes)
• fear of hurting the other person’s feelings
• fear of getting a negative response (eg anger or ‘the working relationship will suffer’).

You decide that you will speak to him. At the same time you are concerned that you might offend him.

What would be your approach and what would you say to Dr Ali?

Such conversations can be difficult because some people do not respond well to feedback. An honest, direct approach, done sensitively, is preferable. It is important to point out to Dr Ali that you are speaking to him because you are concerned for him and you don’t want something untoward to happen. You tell him that poor note-taking is a liability and you explain why it is important to have good progress notes. You also take the opportunity to tell him that his referral letters are scant on information; a specialist will read the letter, and it won’t reflect well on Dr Ali as a professional. You say to Dr Ali that you would like to assist him.

How can you help Dr Ali?

Educate him about why good note-taking is important and what constitutes good note-taking. Provide examples of good note-taking. Review his notes periodically and provide him with feedback. Create a template that will make it easier for him to write referral letters. Recommend that he use the spelling tool to correct errors.

If language is part of the problem, make specific recommendations. For example:

• language classes
• English-speaking practice
  • if there are children at home, converse with them in English (children pick up language, including its nuances, very quickly; they are also very quick to correct mistakes)
  • speak in front of the mirror while listening to how words are pronounced and watching the movements of the mouth and how words are enunciated
  • record speech (providing information or explanations) and then critically listen to it or have someone else critique it
• making more use of various opportunities to listen to spoken English to learn pronunciation and diction: the news on radio or TV, Australian TV series like Home and away or medical programs, audiobooks
• practising reading English to learn vocabulary and language structure: newspapers, simple story books
• reading aloud, pronouncing the words fully and clearly
• training in computer skills and use of clinical software
• writing practice: keyboard skills but also to practise syntax and phrasing.

Dr Omar is a young doctor who goes out of his way to assist his fellow countrymen, many of whom are refugees and do not speak English very well. Not uncommonly, he gives his mobile number to his patients so that they can contact him ‘in an emergency’. A friend of Dr Omar’s, who is also a GP, has told him that he should not give his mobile number to his patients because they will pester him. Dr Omar responds that while he has had some nuisance calls, his patients have generally contacted him only when there has been genuine need. Furthermore, he says that he knows of many specialists who give their mobile number to patients, for emergency contact, so he doesn’t see that there is an issue.

Is it appropriate for Dr Omar to have given his mobile number to his patients?

The answer is not a simple yes or no. It is important to look at the context. In some circumstances it may be entirely appropriate, especially when access to healthcare, and particularly emergency care, is limited. Doctors also have a right to privacy and need time out for themselves and their family. Moreover, it can become burdensome for the doctor when patients call frequently about trivial matters. The other consideration is that of boundaries and with certain patients it may not be wise for the doctor to give them their private number.

Maryam is approximately the same age as Dr Omar. She has seen him infrequently in the past for minor presentations. She attends today for a tetanus injection, having been scratched by her cat the day before. At the end of the consultation, Maryam asks Dr Omar out for coffee. He accepts. They meet and chat about different things. The next night they meet for drinks after work and the week after that they have dinner together. Dr Omar finds himself drawn towards Maryam. She is very attractive and he enjoys her company.

He is not sure whether he is doing the right thing because he has heard that doctors in Australia are not permitted to enter into a relationship with a patient. He asks his friend for advice. His friend tells him that there isn’t a problem because Maryam has been consulting him for relatively minor problems only and that all he has to do is stop seeing her as a patient.

Dr Omar thinks about what his friend has said and decides that he is right.

Is the advice that Dr Omar has been given correct? Has Dr Omar made the right decision?

No, his friend has not given him the correct advice. From the Medical Board’s perspective, it is inappropriate for a doctor to enter into a relationship with a patient, even a former patient.

Dr Omar informs Maryam that if they are to keep seeing each other, he cannot see her as a patient any longer. Maryam understands completely and says that, from now on, she will consult a GP at a different clinic. Even though Maryam does this, she continues to ask Dr Omar for his medical opinion about her medical complaints whenever they meet.

Is it appropriate for Maryam to continue asking Dr Omar for his medical opinion?

No. By doing this, the doctor–patient relationship continues to be maintained.

Six months later, Dr Omar makes an appointment with his solicitor. He is very distressed about a letter he has received from Maryam and mortified about what has transpired. In the letter, Maryam states that she is pregnant, that the child is his and that he must marry her otherwise it will bring shame to her and her family and Dr Omar’s name in the community will be blackened. Dr Omar says that he is compelled to do the honourable thing and marry Maryam, even though he knows that the baby is not his because they never had sex.

Is marriage and the paternity issue Dr Omar’s only problem? Should Dr Omar report himself to the Medical Board?

Dr Omar should not be hasty in making any decisions regarding marriage because he may well regret it later. He should consult his medical defence organisation on the matter. They may advise him to report himself to the Medical Board rather than wait and see whether Maryam makes a complaint.

Mrs Swaminathan confides in Dr Priyanthi, who is also a family friend, that she is worried about her 16-year-old daughter, Usha. She says they are constantly arguing because Usha seems to have lost interest in her studies and wants to go out with her friends all the time. She is also worried that Usha might have a boyfriend and is having sex. She and her husband are beside themselves because their daughter’s behaviour is totally at odds with their family values. She fears what her husband might do if their daughter were to become pregnant. Mrs Swaminathan tells Dr Priyanthi that her fears are not totally unfounded because she found a pregnancy test kit in the rubbish bin last week.

Dr Priyanthi commiserates with Mrs Swaminathan, saying to her that, as a mother, she fully understands her concerns and her fear that there may be dire consequences. She also informs Mrs Swaminathan that Usha attended the clinic last week and that she will look at Usha’s file right now to find out what transpired.

Has Dr Priyanthi acted appropriately?

No. Dr Priyanthi doesn’t have Usha’s consent to tell her mother that she attended the clinic, let alone to look into her file. By divulging information in Usha’s file to Mrs Swaminathan, she will also be breaching Usha’s confidentiality.

How should Dr Priyanthi have acted?

Dr Priyanthi may certainly commiserate with Mrs Swaminathan but looking into Usha’s file doesn’t solve the problem. If anything, it would inflame the situation if Usha were to find out. Dr Priyanthi can certainly say this to Mrs Swaminathan, but more importantly she should also tell her that she cannot look into Usha’s file without consent and that she is bound by strict rules of confidentiality and privacy. Mrs Swaminathan and Usha need to talk and DrPriyanthi’s role could be to bring the two of them together and facilitate that dialogue.

Dr Priyanthi needs to be constantly aware of her dual role as friend and doctor. Interactions of a clinical nature with Mrs Swaminathan should be conducted entirely professionally (with clinical notes) and with continued vigilance as regards impartiality.