When “personal skills” are more difficult to learn than “know-how”

Introduction

In Belgium, specific training in general practice is spread over a period of three years. The first year is integrated into the basic university degree course that totals seven years. It comprises training periods in first-line practice, and courses and workshops at the university. The two remaining years are dedicated to supervised practice in the office of one or several supervising teachers. The young physician is called an “assistant”. During these two years, the assistant participates in exchange and supervision meetings with other assistants, under the control of another supervising teacher who provides the supervision in those meetings. When he/she has completed this specific training, the young physician must present an end-of-studies work in front of an inter-university jury. When the entire training is completed, the young physician becomes a general practitioner in his/her own right, and can set himself/herself up where he/she wants.

Case history

Miss B is 15 years old. She is cared for, as are her parents, by the regular physician of her grandmother. The latter, who lives in the same house, has severe hypertensive cardiomyopathy for which the physician pays regular house calls.

In the summer 2004, during the holidays of the usual family physician, Miss B's mother asks me to call in to see her daughter and to check the grandmother's blood pressure. I propose sending Dr N, a young general-practice trainee in our group medical practice. Mrs B willingly agrees. This first meeting goes smoothly, and Miss B tells her parents that she prefers the young general practitioner, who is much more likeable than the grandmother's physician.

In the following months, Dr N is called several times when Miss B or one of her parents is ill. Then, Dr N occasionally receives SMS messages from Miss B who asks various medical questions. Dr N does not answer the SMS messages, considering this is an inappropriate communication channel between a physician and his/her patient. Afterwards, Dr N receives friendly SMSs. Dr N then decides to point out to her young patient that she is her physician and not a friend. Their relationship is very different from a friendship, and SMSs are therefore not appropriate.

Later, Dr N receives drawings, postcards, and a gift, in addition to the SMSs Miss B keeps on sending. Then, suddenly, the frequency of contact increases, with 5, 10, or 15 messages or cards daily, even at the weekend.

Dr N decides to discuss the situation with her supervising teacher and the colleague that shares the same practice. In the week this meeting between colleagues takes place, a love letter is sent by Miss B to Dr N. The decision, made jointly, is to tell Miss B's parents about the situation, and to recommend a psychological interview for their daughter [1], [2]. The parents accept this advice. A psychologist meets the young girl and clarifies the misunderstanding.

Discussion

This situation encouraged us to reflect on the attitude adopted by the caregiver. What reactions and what attitude would have helped to avoid continuation of the misunderstanding in the young patient?[3].

We think that, as soon as she received the first SMS, Dr N ought to have reacted rapidly rather than leaving the matter and not responding to the patient. The absence of reaction could be interpreted as a tacit agreement. A direct meeting, upon Dr N's initiative, would have made it possible to clarify the situation and perhaps to prevent the continuation of messages and gifts. Dr N did think of doing this, but she also feared losing an entire family of new patients.

On the other hand, we feel that Dr N's attitude in the management of what followed was totally appropriate. She clearly explained to the patient the nature of an acceptable relationship between a physician and his/her patient, as well as the kind of appropriate communication channels. Subsequently, as the problem persisted, Dr N informed her supervising teacher and the caregiving team in order to find the best solution. The young girl's parents were contacted due to the fact she was under age, and we felt a psychological interview would be interesting.

A similar situation with a patient of age requires as much caution in the management of misunderstandings. If role confusion persists in the patient's mind, one should not hesitate to notify the patient of a refusal to continue the therapeutic relationship. In such a case, the patient should be directly given the names of one or more colleagues who could take charge of his/her medical records.

Commentary

There are lessons for all of us here; foremost as doctors but also for those of us who have responsibilities as supervising teachers. The lessons mainly concern the conduct of our professional relationships and the responsibilities carried within those relationships. There is also a lesson for teachers in the guidance that they give young doctors at the start of their careers.

This case alerts me to the importance of reminding all young doctors that they may be attractive to their patients, especially those more vulnerable such as Miss B. Although this is flattering, they need to be constantly aware of their own feelings and their reactions to them. They also need to be sensitive to the feelings, which may be conscious or unconscious, of their patient, which may transgress the appropriate doctor–patient relationship. This becomes clearer with wisdom and experience.

A useful, personal early-warning system is always to take note of the unusual and odd. (In this case, an SMS message from a young patient.) Perhaps young doctors in training, as a matter of course, would do well to report the “out of the ordinary” to their supervisors.

The support and positive affirmation together with the opportunity for reflection given to Dr N by her supervisors is very important. Certainly, I would like to have trained in such an environment.

On the basis of this reflection, three issues emerge. Firstly, an understanding that failure to respond to a patient's communication (in this case the initial SMS message) is more likely to be interpreted as tacit agreement than disagreement. Secondly, Dr N feared losing her new patients. All of us experience this anxiety, especially early in our careers. We need to continually hold firm on professional- ethical behaviour regardless of such pressures. Thirdly, the early alert prompted by the “unusual” might have allowed Dr N to look “behind” the medical questions in the initial SMS messages. She might have found not medical concerns but a somewhat lonely, slightly confused young woman infatuated with her young doctor. Given this insight, a hypothetical early meeting between Dr N and Miss B may have helped Miss B understand the parameters of an acceptable relationship with her doctor and appropriate ways to communicate with her. Furthermore, Dr N would now be free to address the social/emotional issues affecting her patient in a more direct and effective manner. By addressing the underlying problem, Dr N may have been able to prevent the escalation of the problem.

Thank you, Thierry Van der Schueren, for sharing this case with us. Paul Money Drumcliffe, Co. Sligo, Ireland