“Dual relationships” is a term that refers to acting in more than one role with any given patient. There are several ways in which this can happen, all of which are to be avoided. In a previous column last year, I discussed why it is essential that one not attempt to function as both a treating psychiatrist and a forensic psychiatrist for the same patient. There are other such dual relationships that also must be avoided either to avoid potential malpractice situations or ethical violations. There are other such dual relationships you must avoid to prevent either potential malpractice situations or ethical violations.
The first example involves treating someone with whom you have a preexisting relationship which is not of a doctor-patient nature. For example, your secretary has been appearing more withdrawn and quiet as well as sad. You inquire as to whether something is wrong. She bursts into tears and describes how she just isn’t happy anymore, that she doesn’t enjoy life, nothing seems to make her happy, and she doesn’t understand why because there are no situational stressors. Without your asking, she volunteers the information that several years ago she had an episode of depression, which responded to nortriptyline. She thinks she might need an antidepressant, but is loathe to go back on one, because she had problems with side-effects.
She has been an excellent employee and you feel sympathetic toward her plight. You give her information about the newer antidepressants. You think about offering to write her a prescription for an SSRI. You wonder whether you should do so.
Absolutely not! This is something you must not do. Although your wish to help is laudable, the best help that you can give her is to suggest that she seek a medical evaluation. It would be an error to treat her at this point in time because you have not done a diagnostic evaluation, which you would do for any person who walked in your door as a potential patient. You would do a thorough history of present illness, questioning the person in-depth about stressors, possible personality factors that could be involved, as well as screening for any potential physical problems. You have done none of this with your secretary. Thus, your diagnostic assessment is inadequate. Any treatment that flows from the inadequate assessment runs the risk of being wrong, and certainly falls below the standard of care.
Furthermore, because of your preexisting employer-employee relationship, your secretary may feel under an obligation to accept the prescription, and take the medication, because you are her boss, not because she wants to take the medication. Thus, any problems or side-effects she has with the medication will color her feelings about you as a physician and as an employer.
If you are right in your initial hypothesis and she responds to medication, all would seemingly work out well. However, even if it does occur, your secretary may still be left with the feeling that she was forced into taking medication, rather than coming to that conclusion on her own. If the treatment causes her problems, or is not effective and delays her getting appropriate treatment, then you have not been of help by having been an interference in her getting appropriate care. Additionally, you have left yourself open to both a malpractice case and an ethics board complaint.
Doing a more thorough psychiatric evaluation before writing a prescription for your secretary would not change the scenario. You still should not enter into a treatment relationship, as additional pitfalls still lurk. For example, in order to do an assessment, you must ask personal questions. Your secretary may feel under an obligation to answer them because you are her boss, or may feel constrained in answering honestly, again, because you are her boss. In either case, potential conflict is present in the doctor-patient relationship, because the patient is also your employee.
Many of the same issues arise in the context of treating the child of a neighbor or friend. For example, at a neighborhood dinner party one evening, a mother says to you that her eight-year-old son is having troubles in third grade with sitting still and paying attention. She has taken him to the pediatrician, who diagnosed attention-deficit/hyperactivity disorder. The pediatrician recommended treatment, either with methylphenidate or atomoxetine. The mother did not make a decision about treatment in the doctor’s office. Subsequently, she has thought about it and is inclined to start her child on medication. She asks you for information about ADHD, your thoughts about medication, and also asks you to write a prescription, for whichever medication you think is best, if you wouldn’t mind doing so.
As in the above situation with your secretary, it would be inappropriate for you to attempt to treat this child, since you have not done a thorough diagnostic evaluation. In order for you to treat the child, you would need to have the mother and child come to your office, open up a chart, do an evaluation yourself, discuss the side-effects of the medications, and then write a prescription.
You do not want to do this for someone who is a friend or neighbor, again because of this being a dual relationship. Because you have a personal relationship with these people, you should avoid having a professional one as well.
In the situation with the neighbor, it would be acceptable to act as a medical encyclopedia by giving general information about the illness and about medications. It would be inappropriate to advise the mother what she should do in regard to treatment for her son. Similarly, it would be inappropriate for you to write a prescription, either at that time or after performing a more in depth evaluation on your own. Instead, the proper course is to answer any generic questions as best you can, and suggest that she discuss this further with her child’s pediatrician.
Here is yet another example. In the course of a visit regarding his son’s depression, a father tells you about a business deal in which he is involved. He offers you the opportunity to be an investor. Here, again, you must decline, simply on the basis of there being a preexisting professional relationship as psychiatrist to his son. For you to get involved in business dealings with the father can only complicate the treatment. Should the two of you become business partners or associates in any way, the father might then expect special treatment for his son, either through extended sessions, more frequent sessions, preferred times, or provision of services at a reduced rate or even without charge. This would be more likely if the venture produced income for you. On the flip side of the coin, if the deal goes sour, it may leave you with feelings of bitterness toward the father, which can be transferred onto your patient.
In short, a patient is always just a patient. This is the only role that you can serve. If a person is not a patient to you, but you see the person in another role, this person, or members of this person’s family, should not become patients. Following this principle will allow you to avoid one potential malpractice/ethical violation pitfall.