It has been a while since I last updated this blog. In my last article, I promised that I will be writing a series of article in relation to the changing world of medicine but unfortunately I met with a small accident in September while going to work. While I was OK and only hit a divider on the highway, my car was damaged and currently still in workshop. It is really frustrating when you don’t have your own car to travel around. This entire fiasco kept me busy for the last 3 months with Deepavali early this month and some travelling to do.
Medicine is or “was” a noble profession. It started as a science to help humans, to discover diseases and ways to treat them. Early doctors were trained purely by apprenticeship with no formal training or degrees. They did their own research at the back yard and came up with new techniques, findings and even treatments. In the 19th century, our ancestors believed that doctors need some form of self regulation and proper training modules. Thus, registration and regulation of doctors started. General Medical Council began in 1858.
Doctors are the only people on the planet given the rights to collect and record clinical history and confidential informations of a person. It is the only profession which can take detail information about a person which include certain intimate or sensitive details and social circumstances. You need to know every detail about a patient, from travelling history, problems at home, social history, sexual history etc etc. Only then we can formulate a diagnosis and provide treatment plans. The patient trust us to keep these informations as tight as possible and not to release the information to a 3rd party or even to his/her relatives which may even include his/her partner without the patient’s consent. This is where medical records safe keeping and confidentiality comes into the picture. Every medical council in the world has guidelines on these issues. Every doctor should read and understand these guidelines as not to breach ethical and professional bounderies.
Doctor-patient relationship is a unique relationship. We should keep professional boundaries at all times. This is the main reason why we should not be treating our own family members and close friends. Emotion would not allow us to provide the best standard of care to our loved ones. We will be in denial and would not give the best advise. On the other end, patients can become a vulnerable victim to a doctor. Only a doctor knows sensitive information of a patient and thus can easily be blackmailed by a doctor. This is one of the reason why professional boundaries are important to be maintained. This is also the reason why we must be regulated!
The advent of social media has created a totally new set of problems. Many doctors do not realise that social media can blur their professional boundaries. Facebook, Twitter, WhatsApp and many other messaging platforms have created new problems in the medical profession. Let’s look at WhatsApp. Doctors nowadays easily give their phone numbers to their patients, send confidential informations such as blood results etc via WhatsApp to the patient and even discuss their problems via WhatsApp. The doctor believes that he is tying to help the patient but forgets the fact that it can be construed as blurring professional boundaries! Imagine if you message the patient at 11pm at night and the patient is a married lady with some social issues, like problem with her husband etc. Imagine if the patient starts to communicate with you via WhatsApp for her personal matters, presumably seeking advise in relation to her relationship issues etc. This can definitely lead to something more serious like the case over HERE and HERE. Furthermore any confidential information send via WhatsApp etc can be considered as a breach of confidentiality as it is leaving your premise. You got no idea who can see those messages even though the phone number can be the patient’s. It is always advisable to ask the patient to come back to your clinic for any discussion or issues. Never discuss any issues over the phone or via text messages. In India, a reason court ruling determined that telephonic consultation without seeing a patient that lead to death can be considered as culpable negligence which leads to being charged as culpable homicide!
Another issue is Facebook(FB)! Many doctors have FB profiles and some of us are active on Facebook, posting various personal matters and views. Way back in 2011 , BMA (British Medical Association) had already issued warning in the UK that interacting with patients at social networking sites such as FB can lead to blurring of professional boundaries. WE must, at all times maintain the doctor-patient relationship status. Making a patient a “friend” on FB blurs this boundary. Once you become a friend of a patient on FB, the patient can access many personal information regarding yourself, they can probably see your family members photos, your political and religious inclination and even comments that you might have made regarding a patient that you just saw in your clinic. IN fact, I have seen many doctors posting and discussing patient’s history and details in FB. While you may not mention the patient’s name but if that patient is your friend on FB, he will definitely know who you are talking about. Many Medical councils and boards in the world have produced “social media guidelines” and the common advise has always been ” never friend a patient on social media including FB, Twitter etc”. To my knowledge, MMC is yet to issue any guideline on this. KKM did issue a minor guideline 2 years ago after the labour room picture fiasco. Not only a patient can see the “life” of a doctor but the doctor can also “spy” on the life of his/her patient. In 2017 there was even an uproar in Pakistan when a doctor requested a patient to become a friend in FB! It was deemed as a form of sexual harassment and the doctor lost his job!
Whenever I talk to younger doctors in regards to this, I see a shocking face! Many doctors out there do not even know their own ethical boundaries with patients. Some even attend patient’s personal family function and interact with patients as though they are family friends. Yes, you may think that it is nothing wrong BUT as a doctor treating such patient, you should never cross the line. If the patient becomes your family friend then you should politely decline to be their doctor, to safe-guard the medical profession and doctor-patient relationship. THIS is a good article to read “Unhealthy relationship with patients”. I reproduce one of the excerpt here:
Maintaining professional boundaries
Avoid situations that may be misconstrued by the patient – for example:
- Giving a patient a lift home in the car
- Seeing patients outside the surgery without a clinical reason
- Telephoning the patient without a clinical reason
- Having personal transactions with patients, such as lending money
- Conducting non-emergency consultations outside normal surgery hours
- Having conversations with patients of a personal nature.
Medical examinations can be misinterpreted by patients, and they can be left feeling that proper boundaries have been crossed so when conducting examinations:
- Explain if an intimate examination needs to be conducted and why
- Explain to the patient what the examination will involve
- Obtain the patient’s permission before commencing
- Give the patient privacy to undress and dress
- Keep discussion relevant and avoid unnecessary personal comments
- Encourage questions and discussion
- If you can sense that the patient feels uneasy, offer a chaperone or invite the patient to bring a relative or friend.
Be aware of your own vulnerabilities:
- Develop skills in saying ‘no’ whilst maintaining compassion and rapport.
- Be aware of the impact of isolation and take steps to have as much peer interaction as possible
- Do not to be seduced by comments that may appeal to your ego ‘you’re the only person who listens to me and understands me.’
Some of the things you need to consider include:
- Making friends with patients or treating friends as patients can lead to unreasonable patient demands
- Politely decline invitations from patients to be Facebook ‘friends’
- Living and working in close rural or cultural communities means you may be invited to social and community events. You don’t need to decline every invitation you receive but do consider the nature of the event before accepting. And, you must always maintain professional boundaries if you choose to attend
- Accessing patient records for the purpose of making social contact breaches the patient’s right to privacy.
I realise that many junior doctors and even some of my own colleagues do not understand their boundaries. They take it for granted especially doctors in private sector. These doctors feel that it is a form of marketing strategy to be friends with patients in FB, to attend functions organised by patients and make friends with patients as though they are your family friends. Some even question me when I advise them not to do so. It is ethically wrong fo a doctor to breach a doctor-patient relationship. At all times, we should maintain our professionalism and treat a patient as a patient! Never do more than that except in an emergency situation.
I see a very dangerous trend of doctors accepting patients as FB friends etc. Please be VERY careful! It can be harmful in both ways. With increasing medico-legal cases in court, it can only harm you further. We are not any different than judges who have to refrain themselves from many social events.
It has been a busy year for me. I may not be able to update another article within the next 1 month. Thus, I wish everyone a very HAPPY NEW YEAR 2019…………………
Pagalavan's Avatar 
Hope your car gets fixed soonest possible and Early Happy New Year 2019
Dear doctor,
How would you comment on the prospects of pharmacy?
Hi doctor, I am interested to do medical research in the future. Was wondering if becoming a doctor in the future will give me the same opportunities as other scientists of other fields to do medical research. Also, do any doctors or pharmacists actually carry out research in the hospital?
I think many people do not understand about research. There are many types of research. If you are talking about research to discover new drugs etc than these are not done by doctors. Doctors are only involved in clinical research when the drugs are used for human trial. WE are not involved in developing those drugs. Obviously there are doctors who give up clinical practise and does only research but to me this is a waste as you had spent so much money and time doing medicine when you could have actually done a research based programme right from the beginning.
Thank you Dr for your advice. One more question doctor, do you know any pharmacists that work in industry as a researcher?
Yes, there are many
Hi Dr, thanks for your kind sharing to all of us. I am currently waiting for my housemanship while preparing for my FRCOphth part 1 as well. As I read this blog, it helps me reflect about maintaining professionalism throughout the doctor’s career. Just wondering, is it possible to take specialty exam during housemanship?
As far as I know, each college have their own requirements. Some do allow you to sit for Part 1 during housemanship but obviously not for Part 2 as you need some clinical experience before sitting for the exam.
Hi Prof Dr! It is so great to have your precise articles about maintaining professionalism in medical career in a wise and polite manner. I like it very much. Although I am awaiting for my housemanship while preparing FRCOphth part 1, I would remember this and bring into practice in my near future. Hope you could have more articles on medical ethics and personal skill improvement to continue inspiring others! Just wondering, it is possible to have specialty exam during housemanship?
Respected doctor,
I would like to enquire as to is MRCS recognized in Singapore? I checked the SMC website, however I am unable to locate MRCS in list of the postgraduate medical qualification.
In need of your advice.
Thank you.
MRCS is not a postgraduate exam. It is an entry exam to speciality training
Thank you so much for your reply.
But is it possible to use MRCS to apple for residency training programme to overseas such as Singapore, Australia etc?
Singapore yes, Australia NO
Thank you once again for the clarification.
Hi doctor, I’m an STPM leaver waiting for the announcement of my final results. I have been struggling between becoming a forensic officer or a forensic pathologist. From what I know, to become a forensic officer, after degree, I have to become a police officer first and then apply to transfer to the forensic department (which depends on the demand). And to become a forensic pathologist, I have to be a fully registered doctor under MMC and then specialise in forensic pathology. I am aware of the situation in the healthcare industry now (surplus of doctors) and I’m not sure how long will it take for me to become a forensic pathologist. I actually enjoy taking up challenges so I would prefer going to the crime scenes rather than spending most of the time in lab or mortuary. On the other hand, it seems like forensic pathologist has a higher society ranking. It would be great if I can get some advice from you. Thanks for reading!
those who go to crime scenes like CSI are not forensic pathologist. They are forensic officers in police departments. Most of the time, forensic pathologist only do autopsy. Only in high profile cases they go to scene of the crime, just to decide on possible cause of death. Don’t get carried away with TV shows. As for higher society ranking, are you living for yourself or for the society?
Thanks for your reply, doctor. What is your perspective about the future of forensic field? And will it be better than biotech?
Forensic pathologist are all civil servants , thus the number of post are limited. And 1 forensic pathologist can cover few hospitals.
POlice department is of course an expanding department. However, number of post will be limited by financial capability of the government.
Both are government jobs and there are no private jobs for it.
I see. Thanks again!
I hope Doctor or someone reading this post can enlighten me on this. As of latest, for those applying for housemanship without SPM Bahasa Malaysia, can they sit for the exam as a single subject or do they have to sit for history as well or sit for all the 6 core subjects?
The last I know 2 years ago, the minister said that they can sit for BM paper alone. However, I do not know the latest as I have not heard anything otherwise.
Hello doctor! May I know if I can shadow a doctor in any hospital around me? I’m just a college student and I want to experience the daily tasks of a doctor just to see if I can handle it. Can you please advise me on what I can do? Thank you very much!
the best place to do this is in Government hospitals but it is very difficult. You need to talk to the Pengarah of the hospitals.
I see…. thank you for the info!
I guess Kiren Raj did not read your blog, Dr Paga.
why it takes 9 years for that Kiren Raj to study medicine and still not yet finihed?
Hi Dr,
I have passed my MRCS part A and currently in the preparation for part B. May i know does passing MRCS gives us a higher chance of getting into the masters programme? Or do i need to have many publications or research to increase my chance? I am wondering about the importance of research in helping me in getting into surgical training as in my place there is limited chance for research. Thanks in advance.
Supposedly yes but no one will know for sure
Hi Cordy,
I passed my MRCS in 2015. I sent off some case reports for conferences. Got offered into masters on the first attempt. You can put in your c.v. that you’re involved in studies and at the time of your interview you can always slot it in saying that it is ongoing and you are the main author.
helps if you have other co-curricular activities relating to your discipline. i.e. helping a mrcs workshop
best of luck
Hello doc! I am an a level student in Taylor’s :3
I am trying to apply to NUS or one of the oxbridge for med this coming August.. but apparently, from what I have heard, the competition is high (obviously haha xD) so, my lecturer was like ”Your chance is quite low since you haven’t done shadowing and volunteering..”
The thing is, I don’t really know how to land myself on shadowing offer? I tried emailing some doctors but none of them respond huhu..
I have done quite a bunch of volunteering but not med related huhu…
If it’s okay, is it possible for you to give me some tips on how to get myself some shadowing experience? Thanks in advance, have a nice day :3
Unfortunately, shadowing is almost impossible in Malaysia.
Ohh gee, that’s too bad then.. maybe I should try walking around some clinics and ask for a part time job as a cleaner or something and try from there huhu
Hi there
Sorry to hijack this post …I have tried looking to see if there was any previous post about family medicine but I can’t seem to find any. Would you be able to advise regarding the training pathway of family medicine in Malaysia?
I have just obtained my MRCGP in the UK and am considering working in more rural areas in East Malaysia.
Thanks
MRCGP need to undergo gazettement process to be recognised in Malaysia. IT has to be done in a government sector. That’s where the problem comes at the moment.
Good evening Dr, what is the difference between MRCGP and MAFP/FRACGP(conducted by AFPM)?
Anyone can share the experience?
Thank you.
MRCGP is UK and FRACGP is Australian
Good day Dr, have been reading your articles since medical student, they really motivate and inspire me!
Now while waiting for housemaship, I am thinking to take up MRCP Ireland, which only needs 6 months post-graduation.
MRCP Ireland is recognized in Malaysia, but it is less popular here. Do you think it is worth taking sir? Does MRCP(I) holder has any weakness compared to MRCP(UK)? Thanks for your kind reply.
No difference as far as I know. But do you need to be in service in order to sit for the exam?
No Dr, the only requirement is 6 months post-graduate.
Then I shall proceed with my preparation for part 1 MRCP(I).
Thank you!
[…] in my books that was published in June 2016 (Chapter 9, page 185). Along the way I had written numerous articles on issues of doctors and social media. Interestingly, the exact issue that I spoke about in 2015 […]