Meeting purpose

This BC-PAN meeting was a 2-day Zoom conference on October 4 and 5, 2021. The purpose of the meeting was to seek input on the expectations of the public in relation to the few circumstances when health care professionals provide treatment to themselves, family members, and others with whom they have a close relationship.

Key messages from public advisors

• College codes of ethics should include a definition on what good judgement is regarding dual relationships.
• Colleges can encourage the use of telemedicine to better support patients in accessing health care providers outside of their communities.
• Colleges should specify how practitioners should disclose dual relationships to patients so that the patient is aware of its implications and actions to follow up. In social circumstances, it should be up to the patient on whether they would like to disclose the relationship.
• Colleges should engage people using different platforms to inform them of their expectations on dual relationships. Social media may be used in urban centers, but radio and community bulletins may be more effective in rural.  

About the Colleges’ approaches for when health care professionals treat themselves, family members or others close to them

Kelly Newton, CPSBC Policy and Engagement Lead, gave an overview of CPSBC’s Treatment of Self, Family Members and Others Close to You practice standard.

• Treatment of family and friends, as well as self-treatment, should be avoided and health care professionals should refrain from accessing their own health information or the confidential health information of family members or friends.
• Treatment generally includes examining a patient, ordering tests and interpreting results, making and communicating a diagnosis, making referrals and prescribing medications or taking other measures.
• The standard applies when physicians and surgeons treat individuals with whom they have a personal or emotional involvement with, leading to difficulty providing objective diagnoses and care.
• When the patient is a member of the family or a close friend, it may be difficult for a physician to:
  • obtain a detailed (and accurate) medical history
  • conduct sensitive examinations
  • remain objective
  • provide comprehensive treatment options
  • maintain confidentiality
  • access medical records and provide appropriate documentation
• CPSBC’s practice standard principles include college expectations that practitioners:
  • Exercise good judgement when deciding whether to provide medical treatment to anyone they have a close relationship with.
  • Not provide medical treatment to the individuals listed unless the medical condition is minor or urgent and no other physician or surgeon is available.
  • Not provide repeated or ongoing management of a disease or condition to the individuals listed, even where the disease or condition is minor.
  • Not prescribe narcotic medications or psychoactive medications to the individuals listed.
  • Re-evaluate their relationship with the individuals listed when the nature of the relationship has changed to determine if they can still provide care without bias.
  • Transfer care of the individual to another qualified health-care professional as soon as it is practical if their professional judgement has been reasonably affected by changes in the relationship.
• BC-PAN input will be used to review this practice standard and create a new “What to Expect” patient resource.

CPTBC has been challenged to rethink their standard because it neglects the reality of rural practitioners. CPTBC students did qualitative research on boundaries and how it looks in rural and remote communities and coined the term ‘screen door consultations’, where professionals are part of the community. Professional and personal lives are interwoven that aren’t common in urban areas.

CDBC encourages the public to utilize virtual care and dial 811 to find a dietician outside of their community.

Advisor questions and comments

• When complaints or concerns are brought to your attention, who is bringing the concerns forward?
  • Complaints regarding dual relationships are very few and far between. Complaints on this topic is more common in urban areas.
  • Sometimes colleges hear from insurers that there is potential for a conflict of interest. Insurers may question health professionals’ objectivity if they are writing a report about a patient to ensure that the report is truly objective and is not influenced by the patient who is a friend or family member.
• Medical records and privacy are huge pieces, and this could cause privacy concerns.
• There is a sociological difference for people in small communities for what people know about you. In urban communities their social interactions are more controllable about who knows what about them.
• If you are a practitioner and have an office and you have your boundaries around confidentiality, what is your obligation in terms of the staff that you have hired?          
  • Medical Office Assistants fall under practice standards, so they have the same privacy obligations as the practitioner.

Plenary group discussion

Advisors responded in the chat, answering:

What might be the key risks associated with a health care professional treating friends, family or themselves?

• Breach of confidentiality/protection of personal information.
• The pre-established level of trust impeding objectivity: when you are being treated by someone who you are familiar with, there is pre established trust that you think that they know what is best for you and you may not be as inclined to ask questions. One may be reluctant to ask questions because it may seem like they don’t trust the practitioners or respect their professional opinion and may fear that it will affect their other relationship.
• Social or personal embarrassment resulting form breach of confidentiality.
• Fraud in extreme cases (insurers and completing documents).
• Long term responsibility of outcomes: if a health care practitioner gives medical advice to a family member and the outcomes are negative.
• Greater emotional involvement on the part of the practitioner when caring for someone close to them.
  • Burn outs of medical practitioners, work extends beyond the working context and into personal lives.
• Acting without clarity.
• Not fulfilling the professional role that the practitioner plays within the relationship and the burden of a health problem that cannot be easily solved.
• Indigenous people have issues with therapists breaching confidentiality: it is hard for secrets to stay secret because therapists and those who caused trauma are within the same community. Can therapists from a different community be brought in so sessions can be more confidential?

When might treating a close friend or family member be appropriate? When might it not?

• In an emergency when someone needs services immediately.
  • Ex. A friend of an advisor fell out of her bed and broke her hip. She called her son who is a doctor and he assessed her hip and arranged for her to go to the hospital.
• Treating minor, non-urgent conditions one time. Ex.  Standard first aid.

Expectations of health care professionals when treating themselves, family members or others close to them

Public advisors went into break out rooms to discuss:

What considerations should there be for health care practitioners who are working in remote and “niche” communities where there may be few health professionals available?

• If a patient has the same practitioner as their partner or another family member, confidentiality issues may arise.
  • Sharing a health care provider may be problematic. It is important for the practitioner to recognize the conflict.
• There should be an easy and understandable way to recognize, declare, and manage a conflict of interest.
  • Ways to mitigate risks of confidentiality breaches, fraud, and preferential treatment.
• Practitioners should establish a reputation for maintaining confidentiality.
• There needs to be explicit guidelines in place for administration and HR staff because they may be the source of disclosing confidential information.
• Clearly outline that it would be the client’s choice to disclose a dual relationship, not the practitioner.
• Balance the risk of dual relationships with the benefits to patients, like having a practitioner who has an ethnic/language bond and trust that comes with this.
• The ability to switch on and off from a professional relationship should be part of professional training.
• Recognize that trust can be a benefit and a downfall.
• Practitioners must be careful when providing medical advice to friends and family.
• The location of where treatments occur plays a large role because the professional environment may impact the perception of the relationship.
  • Minor and urgent conditions are likely to occur outside of an office setting.
  • Boundaries are less clear in a social environment compared to professional.
• Ensure that there is clear and transparent record keeping.
• If there is no easy option to leave the community to get care from another practitioner, patients may choose to not get care.

Which principles in CPSBC’s Treatment of Self, Family Members and Others Close to You practice standard are most important to you? Why?

1. Exercise good judgement when deciding whether to provide medical treatment to anyone they have a close relationship.
   • What is good judgement? There should be a college definition. 
   • Colleges codes of ethics should include what good judgement is especially regarding dual relationships.
2. Not provide repeated or ongoing management of a condition, even when the condition is minor.
   • The more times a practitioner provides care, and nothing goes wrong, the practitioner may get used to providing this on-going care.
   • This is contingent on access and scarcity of resources.
   • May be difficult to practice if the practitioner has specialized knowledge.
3. Not prescribe narcotic medications or psychoactive medications.
   • Important to manage risk for practitioners.
   • If there is a limited supply of medications, there may be potential for practitioners to give preferential access to medications.
   • CPSBC should consider adding cannabis to this principle.
4. Re-evaluate relationships with family members and others close to practitioners when the nature of the relationship has changed if they can still provide care without bias.
   • The practitioner must re-evaluate the relationship for bias.
   • From our conversation on informed consent, the practitioner is obligated to make the patient aware of all their care options, so the patient has control of directing their own care.
   • Colleges can provide a standard disclosure statement addressing the dual relationship that is transparent to the patient and lists the options for the patient to help facilitate a transfer of care if needed.
5. Transfer care of the individual to another qualified health care professional as soon as it is practical if professional judgement has been reasonably affected by changes in the relationship.
   • Important to manage risk for practitioners.
   • Virtual care is an important resource to offer to rural communities because it provides alternatives.

Which expectations in CPSBC’s practice standard would be helpful for the public to know about? Why?

1. Not provide repeated or ongoing management of a condition, even when the condition is minor.
   • Helps the public know that there are circumstances where a practitioner close to them can offer treatment, but it should not be on an ongoing basis.
2. Exercise good judgement when deciding whether to provide medical treatment to anyone they have a close relationship.
   • List clear ways in which health professionals will address the risks of the dual relationship.
   • The public may assume competency of the practitioner which may affect the relationship.

How could these be communicated to the public in an understandable way?

• In visual form, i.e. a poster, brochure.
  • Disseminate in centers where people can expect to receive this information. Community newsletters, long term care facilities, assisted living, medical offices, etc. 
• In rural communities, radio is often used to provide information. It is especially useful for seniors.
• A short informative ad may be an affective way to communicate this on social media and television.
• Be aware of the digital divide between different generations.
• Communicate this information directly to the patient. The onus is on the professional to disclose and refer the client to any resources.
  • The practitioner can direct the patient to the colleges’ resources.
• Not many people use the college websites, but a “what you need to know” section on the website may be helpful.

What should colleges do to support patients in these circumstances to ask questions of their practitioner, seek alternative treatments or a second opinion without fear of harming the relationship?

• Be aware of social/cultural implications. In some communities, harmony is very valuable.
• Help patients become aware of the professional duties in a relationship and college guidelines.
• With the advantages of telemedicine, colleges can support practitioners and patients to access other health care providers outside of their communities.
• Make sure the public knows that the relationship can be terminated; frame it around informed consent.
• Use scenarios and previous conversations to explain the nuances of dual relationships.
• Requiring that college’s Code of Ethics be visible in the practitioner’s office and can inform clients on expectations of the therapeutic relationship.
• Support practitioners on how to manage dual relationships and provide guidance on how to address and disclose the relationship with patients, with what resources to refer the patient to, all in the best interest of the patient.
• Address referral issues with practitioners so they can make referrals in an unbiased way.
• Provide specific administration staff resources.

How would you want to learn about college standards on this topic?

• Videos with scenarios
• Community resources
• Learning resource section on college website
• Directly from the practitioner when it is relevant
• With Indigenous patients, refer them to relational care, trauma-informed care, and health care reconciliation resources.
• Social media (short YouTube videos, Instagram reels/Tiktoks, and Facebook).
• Use effective Twitter hashtags to get into niche communities.