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At the heart of general practice since 1960

Over-familiar patient

When a patient's overfriendly manner makes you uneasy, play it cool, argues Dr Chris Hall

uch is written about the unique doctor/patient relationship. We have continuity of care with our patients and may have an ongoing relationship with some for most of our working lives. Continuity from cradle to grave is lauded as the keystone of NHS care and it is highly valued by patients, but like all relationships, it can become dysfunctional.

Your surgery door swings open. 'Hi doc, good to see you ­ you're looking good today!' Your heart sinks, your toes curl as you realise the moment has arrived for yet another lengthy consultation with a patient who is fast becoming over-friendly.

'How's the family? Three kids now, isn't it? Yes, I'd heard that on the grapevine. Keeping yourself busy, aren't you? And your wife, for that matter! Still living outside the town? Just that I sometimes see you driving into work past our place. You really must pop in sometime.'

This is an extreme example, but many of you are probably familiar with the distinctly uneasy feeling of dealing with the over-familiar patient. They are hard to stereotype

­ they could be any age or sex, or from any social class.

Some doctors are at ease with this degree of familiarity, they may even thrive on it. But for many it adds a negative, touchy-feely dynamic to the consultation. And it is not without its pitfalls.

First-name terms are the most obvious manifestation of a relationship going beyond the strictly professional and taking on a more personal nature. If you feel uncomfortable about this, it is quite reasonable to politely tell the patient. You could soften the blow with: 'I hope you don't mind, it's my policy with all patients.'

You may find it more prudent to continue addressing them formally. The difference will soon become apparent and may make the patient change their behaviour. First-name terms make it difficult for you to refuse requests ­ especially for house calls, inappropriate sicknotes and requests for a second opinion.

Beware patients bearing gifts. Although many are genuinely given as a token of appreciation, some may be manipulative tickets for 'services yet to be rendered'.

I tend to keep a simple record of gifts (including the date, the name of the patient and details of the gift) for probity and partnership reasons. Monetary gifts are more awkward. The larger the gift, the more potentially awkward it is. Check if your practice has a policy on this. Do not be afraid to refuse a gift ­ but be consistent.

If you suspect a patient is making inappropriate advances, or 'coming on' to you in any way, simply back off. Speak to a partner at the practice and document your conversation. Arranging for the patient to be seen in future by another doctor would seem prudent, at least in the short-term.

Discussion with your medical defence organisation is sensible. Even if you find it embarrassing, it is better to handle the situation early than to let it get out of hand.

Think carefully before sharing family details or using your own family as examples of 'what I did in the circumstances'. You may be imposing moral standards on the patient and diminishing their right to decide what is best, which flies in the face of the principle of informed consent.

Some doctors relish over-familiarity with patients; they see it as an essential part of their role at the heart of the community. But whose unmet need is this really? Others who value their privacy more and squirm when stopped in the supermarket or out for a walk will counsel caution. Do what makes you feel comfortable ­ but remember, in some circumstances, familiarity may breed contempt.

Doctor-patient relationships can easily become dysfunctional~

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