Thursday, 26 January 2012

"at all times..."

The Passage of Time 
The Passage of Time by TonyVC

EDIT 6/5/2013
'at all time' has been removed from Good Medical Practice 2013
Used to be:
57 You must make sure that your conduct at all times justifies
your patients’ trust in you and the public’s trust
in the profession

65. You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession.
The GMC, the body which regulates doctors in the UK,  is consulting on the next version of Good Medical Practice. The consultation ends on Friday, 10th February, 2012 and you can learn more here. Since 2005 Good Medical Practice has been the core guidance for doctors on how they should act professionally. In a previous post written almost exactly 2 years ago I discussed the fact that  the guidance states "You must make sure that your conduct at all times justifies your patients' trust in you and the public's trust in the profession." but does not make clear what kind of conduct might be expected to reduce confidence in a doctor or doctors as a whole. It is perhaps deliberately vague.

The last version of Good Medical Practice was issued in 2006. Times have changed since 2006 and in this consultation the GMC have started using social media to spread the word about the consultation and get some informal feedback. They have started a Facebook page and a twitter account, @gooddoctoruk

There has been a lot of discussion of the consultation on Twitter, primarily around how much doctor's lives outside their hours working as a doctor should be regulated. Do we have to be professional "at all times"?

To get the debate going Shree Datta, co-chair of the British Medical Association's Junior Doctor's Committee wrote a piece on her thoughts around the current guidance on conduct outside of work. She thinks that in the current guidance there  is "little reassuring detail" about what might be considered appropriate or inappropriate. She says: "The simple fact is that people make mistakes and it is unrealistic to expect doctors alone to remain flawless at all times in every aspect of life. Yet the current guidance suggests that that is what is expected of doctors and arguably does not ringfence our privacy or allow for our personal autonomy."

The GMC then asked the question "Do you think the GMC should regulate doctors lives outside medicine?" This was the response from 1167 people. 94% said No.
The GMC have responded to this saying:
"Most commonly fitness to practise cases citing this paragraph arise where doctors are convicted of criminal offences, accept cautions or equivalent sanctions across the UK. But occasionally we also take action on doctors’ registration as a result of doctors’ behaviour in the public sphere, which while not illegal, may undermine patients’ or public trust in the profession.
The rationale for this has always been that patients need to trust their doctors absolutely. Many patients will be vulnerable when they seek medical care and need to be able to trust doctors implicitly.
For the doctor/patient relationship to be successful, patients must trust doctors to be honest and to act with integrity in their patients’ interests. Patients do not want their doctors to have criminal convictions, particularly for violent or sexual offences, and they may not want to be treated by a doctor whose conduct they find morally repugnant or unacceptable. For example, many people would not want to confide in, or agree to be examined by, a doctor found guilty of crimes relating to child abuse or child pornography, even though there was no evidence that the doctor was clinically incompetent."
The comments that the GMC have shared from people who said No in the poll suggest that they thought that there were being asked about the regulation of activities which would usually be considered legal. But by their response it seems that the GMC think that this question also relates to taking action if a doctor is convicted of illegal activity.
Now we have gotten to the stage of the official consultation. Here is the question that doctors  and others are asked to respond to:
"In September 2011, 1,167 people responded to our online poll asking how far the GMC should go in regulating doctors’ behaviour outside medicine. The vast majority (94%) thought the GMC should not take action against doctors for their conduct outside medical practice. We think that if a doctors’ conduct undermines trust in the profession. It should, in some cases, lead to action on their right to practise medicine. (This approach is also taken by other health regulators in the UK). We therefore think it is important to make this clear in Good Medical Practice (see paragraphs 67–8 of the consultation draft).
Do you agree that the guidance achieves a fair balance in terms of the GMC’s role and remit?
Yes      No      Not sure"
This is section 67-68
67 You must be honest and trustworthy in your professional practice.
68 You must make sure that your conduct at all times justifies your patients’ trust in you and the public’s trust in the profession.
This wording is actually very similar to the current version which can be seen here. 
On Twitter some have suggested that since the GMC "did not get the answer they wanted" in the pre-consultation they have simply asked the question again. The GMC have responded through twitter that the pre-consultation activity was just that; a full consultation was still needed. But it is interesting that the strength of feeling about the question above has made it into the official consultation documents.
So are we experiencing a shift in how doctors think they should be regulated? Do we think that as long as we conduct ourselves appropriately during the working day then it does not matter what we do out of hours?  Should the GMC take any action against those who receive a criminal conviction? What does it mean to be professional in the 21st century? 
It's certain that this topic is going to be discussed for a long time.

By the way, if you look at my old post you'll see that whether patients trust doctors seems to be based on their interactions with them as a professional. We don't know what impact other factors have.

EDIT: Initially this post stated that the poll was of 1167 doctors. This was wrong. The poll was open to anyone and it is not known how many respondents were doctors.


  1. Occasionally we also take action on doctors’ registration as a result of doctors’ behaviour in the public sphere, which while not illegal, may undermine patients’ or public trust in the profession.

    This is a very open statement and it could be that this might extend to such things as extramarital affairs of the type that the Daily Mail loves such as love triangles, bisexuality etc. These have no real bearing on a doctors clinical practice but the sort of thing tabloids love because as a profession we are still held in relatively high esteem despite their best efforts.

    The line is far too hazy for my liking.
    P.S. Not involved in love triangle or the like!

  2. Hello James,
    Thanks for starting the ball rolling. Is there any evidence that doctors have been disciplined because of love triangles, or bisexuality etc?

    Is this something that the loose terminology that the GMC have used makes doctors worry about although in pracice it doesn't happen?

    And in other professions who use similar language about trust, or even 'upholding the reputation of the profession' are there the same concerns that they could be disciplined for (im)moral behaviours?

    Thanks again,

  3. Hi Anne Marie
    Think the blog is interesting and thought provoking and to a large extent also applies to nurses. We, too, are professionally regulated and the final statement in our regulatory code of conduct is:
    'You must uphold the reputation of your profession at all times'
    I suspect we will be watching this debate and outcome with some interest!

  4. "At all times" does seem a little much. As far as I know there is only one infallible person on earth. And depending on your religious persuasion even that is open to doubt!

    Surely this is setting up an impossible standard, especially in today's inter-connected world where it is actually much easier to see what people do inside and outside of “work”.

    Social Media and Social Networks have made the world and our communities much smaller – there are fewer places to be private now, so the phrase “at all times” does seem outdated and archaic.

    I have a little knowledge of other professions e.g. Solicitor's code of conduct, revised in 2011 uses the following phrase:

    "…behave in a way that maintains the trust the public places in you and in the provision of legal services.."

    See here for more details:

    But it is interesting.

    We the public do have a high regard for our doctors. Certainly the relationship I have with my doctor “feels” different to that of my Accountant or Solicitor. On reflection now, perhaps my expectations are a little too high. After all, doctors are just another profession, providing a service that I need. I think also, because of the availability of health information and more knowledgeable patients the doctor-patient relationship is not quite as sacred as it once was. To that end, “at all times” does seem inappropriate.

  5. Hi Annie,
    Yes, the GMC dropped the 'You must uphold the reputation of your profession at all times' line with the introduction of Good Medical Practice- but interestingly the phrase is still often used in Fitness to Practice procedures as I describe in this post.

  6. I think it is the open endedness of the statement that worries me most. I was really only using the affair scenario to demonstrate the point. Affairs do damage reputations and if a doctor is involved then the tabloids love it and it does potentially damage the reputation of the profession. I am not aware of a GMC taking action.

    Maybe I am too cynical of authorities using rules to follow a different agenda.

    Could this wording also be used as a threat / gagging order if doctors are trying to point out flaws within seniors within their own profession. I was not personally affected by MTAS but it has made a generation of cynics.

  7. Hello Fiona,

    Thanks for your comment. It is really interesting to get your perspective. I think one way of figuring out if the GMC have impossibly high standards is to consider what doctors are actually disciplined for. As they state above this is usually only applied to criminal convictions. Should they not be considered by the GMC? Is committing a crime a sign of being human?

  8. Great post! I'm going to reframe the GMC question into social work terms if you'll allow me because we have had similar discussions in our profession as the GSCC (regulator) demands similarly that outside of work we maintain a certain level of conduct and social workers have been 'struck off' for behaviours outside work.

    I see it from two sides. I can see why someone would find it difficult that a professional regulator has any redress over actions that occur in the 'private' sphere but equally, I can see how in some professions where trust is so fundamental that it may be an issue.

    Personally, I think a professional code should follow me in my actions and am happy to accept that into my personal life but I may well be in the minority.

  9. James,

    Thanks for getting back to me!
    "Could this wording also be used as a threat / gagging order if doctors are trying to point out flaws within seniors within their own profession."

    You know that today the GMC published guidance which should actually support whistle-blowers?

    Are doctors more cynical than ever these days? Perhaps the public and patients are also getting more cynical about doctors too!

    Thanks again

  10. Thanks Ermitrude :) It's very useful to hear from those in other professions who have similar professional guidelines.

    You seem to be suggesting that it is hard to split of professional selves from personal selves.

    I wonder if the 94% who answered No disagree, or if they thought they were answering a different question to that which the GMC thought they were.


  11. Anne Marie,
    The Guardian article is very interesting because the GMC are advising against doctors vs employers and whistleblowing which is not quite the same.

    I am talking internal political hierarchies within medicine which are very powerful. These were the structures that created MTAS and many juniors still feel very angry and cynical as a result of this.

    Rightly or wrongly the GMC are seen as part of the political institution within medicine and therefore 'who watches the watchers comes to mind'

    COI As an appraiser I could be deemed to be a watcher myself!

  12. Such an interesting debate as they always on your blog, Anne Marie.

    I'm an OT, and our regulation through the HPC similarly requires good conduct of registrants. I think the context of how these rules apply is important, and perhaps it is helpful to examine the recent decisions relating to fitness to practice investigations to see how the rules apply in practice.

    The public is free to follow the fitness to practice activities of the HPC through the website and my feeling is that this is good and very transparent. In fact, when browsing the decisions made, I am often struck by the numerous efforts made by the regulator to give any registrant time to amend the behaviour at issue, or show that they understand how it could impact on the profession's standing.

    For example, having an addiction problem is never cited as a reason for striking off, but either accessing prescription drugs inappropriately, or being under the influence of alcohol at work often are. I don't think I can argue with this- what would it say about the profession if actions that would lose you your driving licence if you were a trucker would not lose you your fitness to practice as a Doctor (or an OT)?

    I've just read a case on their website where someone convicted of drink driving for the second time in three years was sanctioned. They were given a five year "caution order", not suspended or struck off. They give the legal framework for the decision. I feel it is appropriate that if an individual in a position of trust and responsibility within the health professions, and their actions put the public at risk, then they should receive sanction. I believe this to be the case whether or not that happens at work, although the degree of the sanction should reflect the difference in risk to the public. I don't see our regulator using these sanctions in a punitive manner.

    I wonder why so many Doctors didn't believe their actions within their private lives would impact on the standing of the profession? I would expect any Doctor who broke the law to have the incident properly investigated by a regulatory body, and I would expect an appropriate sanction to be applied. Anything less would seem to me to be evidence of putting the Doctor's welfare aboe that of the public- and isn't the rule "First, do no harm"?

  13. Hello again James,

    I'm not quite sure what you mean by "the GMC are advising against doctors vs employers and whistleblowing which is not quite the same".

    The new guidance states:
    "Duty to raise concerns
    7. All doctors have a duty to raise concerns where they believe that patient safety or care is being compromised by the practice of colleagues or the systems, policies and procedures in the organisations in which they work. They must also encourage and support a culture in which staff can raise concerns openly and safely.
    8. You must not enter into contracts or agreements with your employing or contracting body that seek to prevent you from or restrict you in raising concerns about patient safety. Contracts or agreements are void if they intend to stop an employee from making a protected disclosure.*

    *The Public Interest Disclosure Act 1998 protects individuals making disclosures that ‘tend to show’ that the health or safety of a person is or may be endangered. These are ‘protected disclosures’."

    I'm taking that as being in support of whistle-blowing and against gagging clauses.

    Yes, I understand your sense that within the medical community there is cynicism about the political institution of medicine. But I'd hazard a guess that those outside of medicine might be surprised at this. That was what I was trying to say.

  14. Hello Claire,

    Many thanks for taking the time to comment. The GMC is also transparent in it's decisions. They are all published here.

    I think there has been some confusion about the question asked in the pre-consultation suggest that they thought they were considering illegal activity. But it seems that by the GMC's reply they thought there were asking about legal and illegal activity. That is where a lot of the confusion lies.

    That is my understanding at least. I hoped this post might bring some clarity but I can see that it is still very confusing!


  15. Thanks Anne Marie,

    Yes, I see that the guidance covers both legal and illegal activity. I was using the example of illegal activity because it is far more open-and-shut.

    Legal activity that damages the profession's standing would, of course, also include activity which did not result in a criminal conviction. Which is not the same thing as harmless activity!

    Medical malpractice is one such example. If a Doctor is consistently failing to provide proper and appropriate care for a patient should s/he not face sanction? How about a case where a Doctor misrepresents someone else's blood as their own- does this deserve sanction?

    I'm interested to hear in what circumstances misconduct and mischief could be said not to affect the standing of the profession, with particular reference to the examples of fitness to practice investigations available through the GMC site.

  16. Claireot says: "I wonder why so many Doctors didn't believe their actions within their private lives would impact on the standing of the profession? I would expect any Doctor who broke the law to have the incident properly investigated by a regulatory body, and I would expect an appropriate sanction to be applied."

    I do not think many doctors are questioning whether or not unlawful activities should come to the attention of the GMC. Most of us are up in arms over the ambiguity of what activities, in their private lives, the GMC felt was appropriate for them to regulate. A one off drunken dancing on the tables at the village pub? An affair with a married person? Multiple sexual partners? Frequenting the bookmakers? Falling out of nightclubs every Friday night? There simply is no guidance and any of these actions could, potentially, be said to bring the doctor and the profession into disrepute although none of them are illegal.

    Please also consider the fate of doctors who are subjected to fitness to practise investigations by the GMC. Even if they are cleared their careers can still be blighted. People often say "no smoke without fire". This isn't always true though. False, ill-advised or simply plain vexatious complaints can all affect a doctor's career, even when they are cleared by the GMC. This is another reason why it is very important the GMC clarifies matters.

  17. Thanks Anne Marie - at least someone is scrutinising this and distilling some important points with huge implications!

    While there is no doubt the nature of medicine means patients must be able to trust their doctor, and it is fortunate that doctors are still the most trusted profession according to Ipsos Mori polls, I worry about the GMC's suggestion that doctors must ensure their conduct "at all times" justify the patients' trust in them and the public in the profession.

    Modern technology means it is more difficult for a doctor to keep their lives and opinions private. For example, Facebook, Twitter and other social media sites enable the public to know what doctors get up to at all times; when are doctors doctors, and doctors people?

    It seems cruelly ironic that while efforts are rightly made to improve patient empowerment with health service rating websites and legislation/governance processes to protect confidentiality, doctors are becoming more open to scrutiny by the public and their professional regulator.

    Much of medicine is about managing and living with uncertainties; not only does a doctor worry about their professional practice and risk of complaints or litigation regularly; in future, we may have to worry about how we are judged by the public what we do in our spare time.

  18. Hello again Claire,

    Gosh I must have got you really confused. This is not about medical malpractice. Of course doctors are expected to provide high standards of clinical care and that is covered very clearly in Good Medical Practice. No one (as far as I know) is suggesting that clinical work should not be regulated! That would be astounding!

    Instead here we are talking about what happens outside of work. You say: "Legal activity that damages the profession's standing would, of course, also include activity which did not result in a criminal conviction. Which is not the same thing as harmless activity!"

    What kind of legal but not harmless activity are your thinking about? Remember we are talking about activity that is not directly related to being a doctor in any way.

    As Ditzy points out people are "up in arms" about the lack of clarity on which legal activities in doctor's private lives should be regulated.

    On the other hand, I'm not aware that any doctors have been referred to the GMC because of dancing on tabled or multiple sexual partners or an affair with a married person. It seems that people are afraid that this might happen rather than that it actually has.

    Still, the GMC do say that at times they have used this clause to take action against doctors when the activity has not been illegal. I don't think that any of us are aware of what those activities are. And I think that is what Ditzy and others are asking for clarification over.

    Does that make sense?

    And thanks a lot for your comment, Ditzy:)


  19. Yes, Thanks Anne Marie and Ditzy.

    I can understand the concern when the rules are not clear- are there instances where we don't have information on how the rules HAVE been applied, or is the main problem the POTENTIAL way they could be applied? (sorry, it's late, my brain slows down at 10.30pm)

    I can't see how a fitness to practice investigation could justify hauling a Doctor over the coals for a marital indiscretion or similar. How could you justify the cost of the investigation?!

    Do you think this new emphasis is related to the changes in the NHS, perhaps the expectation of "whiter-than-white" morality "at all times" relates to this in some way?

    FWIW, I do think Doctors should conduct themselves "at all times" with due regard for their professional standing. Nowadays, a videoclip of a drunken friend can be uploaded to YouTube, tagged, and seen by hundreds on Facebook before the individual has even sobered up. If that person is recognisable as a Doctor, I can see this being an area of concern for the GMC- do we need new rules for Social Media?

  20. Hello Richard,

    Many thanks for your comment.I'd like to pick up on your point that we are 'becoming more open to scrutiny'. I agree that through the use of social media it can be much easier for doctors to make others aware of what happens in their private life than it used to be.

    But that still does not solve the question of what are the activities that might be deemed to reduce trust? Social media may make our private lives more visible but surely it doesn't change the nature of what is considered acceptable conduct. Does it? Again this brings me back to the conclusion of my previous post- we should determine what is acceptable or unacceptable conduct; how one becomes aware of that activity is secondary.

    I have to say that I think it is unlikely that social media will have the impact you think. I've make more that 50,000 tweets. What am I telling the public about my personal life except that I think about work quite a lot when I am not actually there! But that is the lot of a doctoral student as you know:)

    I think we are getting somewhere but this needs a lot of teasing out.


  21. Hello Claire- thanks again!!!

    I can't see that a FTP investigation would be carried out because of a marital indiscretion either. I get the sense that people are concerned because of the potential rather than actual cases.

    In my previous post I quoted an old version of the guidance which stated "convictions for drunkenness or other offences arising from misuse of alcohol (such as driving a motor car when under the influence of drink) indicate habits which are discreditable to the profession". We might wonder what are 'habits' that are discreditable to the profession.

    It's interesting to look back at this article from almost 40 years ago
    Very few doctors were referred to the GMC for moral behaviours then either.

    But looking back to 2006 it seems that the new GMC guidance saying that doctors behave well 'at all times' was slightly controversial at the time ( though I can't remember that!

    Going back to your point about YouTube. Are you saying that a doctor should never get drunk in case it ends up on YouTube? Should the GMC take any action if a doctor is seen drunk on YouTube?

    If a doctor would not have been disciplined in the past for having been seen drunk once then I can't see why they should be disciplined because the same activity now appears on YouTube.

    However, just because someone is not disciplined does not mean that a patient or a colleague or a boss might not think differently about us because of what they come across in social media. There is nothing that can be done about that. But it does not mean that a disciplinary offence has occurred.

    By the way, the GMC does intend to introduce guidance on social media. This current consultation version of Good Medical Practice reminds all doctors that what they publish on social media may be seen by more than they originally intended. But it does not suggest that this might mean that disciplinary action will be taken.

    Thanks again
    Anne Marie

  22. Anne Marie,

    Your post also said that the GMC investigates in circumstances even if the behaviour is not illegal but it is in the public sphere and impacts on public trust.

    So perhaps the issue is less about humanity and more about what actually constitutes trust - which I notice comes out in some of your other comments. I once read that how people trust you is a combination of who you are (your character) and the results you deliver (your competency). Is it possible to separate results from character? Is that what the debate needs to be about?

    I guess it is all about clarity at this stage. I think if I was a doctor, I'd be asking why the wording change has been deemed necessary. "At all times" is just way too vague and practically impossible to police never mind uphold.

    In the end, I just find this all a bit confusing...and kind of want to say - if it aint broke, don't fix it :)


  23. Hello Fiona,
    Thanks for making the effort to reply. Trust is the key issue- ans is there a difference between trust in an individual and trust in a profession?

    By the way, the wording changed in 2006. There has been no change in this draft but it seems that some (?many) doctors are unhappy with the current and new draft wording. But what would be better?


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