CLINICIANS AND

RELATIONSHIPS
Dr. Habineza Paul de Rire
Eden University
SOM&HS
Eden University Medical Ethics
Dept. of Clinical Sciences
 INTRODUCTION
Clinicians work closely with nurses, pharmacists, social workers,
physiotherapists and many other professionals in delivering
health care. The quality of this care is enhanced in these working
relationships if there is good communication, mutual respect and
a proper understanding of the roles, responsibilities,
capabilities, constraints and ethical codes of these various
professions.
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 THE LEGAL AND ETHICAL CONTEXT
All health-care professionals, including clinicians, share similar ideals, being
concerned with helping people to prevent or overcome illness, relieving
suffering and maintaining life of good quality. These professionals share
similar ethical codes, being bound to respect patients, maintain their
confidentiality, be honest and behave with integrity. Most are subject to legal
regulation through a registration process, with disciplinary mechanisms for
professional misconduct, and mechanisms to deal with practitioners whose
health is impaired to the extent that the public is at risk. Some of the
legislation also places limits on the scope of practice of the health-care
professional

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 NURSES
In their undergraduate and postgraduate training, clinicians work
alongside nurses and thus clinicians may well feel they are familiar
with the training of nurses and the scope of their responsibilities.
In the nurse–clinician working relationship of caring for patients, there
are responsibilities which are clearly those of nurses, clearly those of
clinicians, and responsibilities which may be shared. Even when it is
clear where a particular responsibility lies, there are overriding
responsibilities for both professions to act always in the best interests
of the patient.
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 NURSES
Misunderstandings in regard to responsibilities will be prevented
if there is a collaborative partnership role of mutual respect and
appreciation of the training, philosophies, skills and expertise
each profession brings to patient care. Where differences arise, as
they always will in the complexity of hospital practice and health
care, open respectful discussion achieves the best for the patient,
while allowing each profession to support the other and providing
checks and balances when needed.
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 PHARMACISTS
The role of pharmacists does not overlap to any significant degree with that of
clinicians and in general there exists mutual respect and little sense of competition.
However, clinicians and pharmacists have individual and joint responsibilities to
ensure that patients use medications safely and effectively.

The commonest problem that arises between clinicians and pharmacists relates to
communication, usually due to a failure on the part of the clinician. Much less
frequently, interprofessional tensions arise when clinician seek to dispense and sell
medications or when clinicians misunderstand the role pharmacists legitimately
play in giving advice and recommending medicines.

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 PHARMACISTS
Pharmacists expect and rely upon clinicians to write legible
prescriptions with clear instructions as to how the medication is
to be taken. By law, pharmacists cannot fill a prescription unless
the pharmacist is certain of which drug is being prescribed and
what directions have been given for its administration. Clinicians
expect pharmacists to accurately dispense the medication
prescribed and to attend to labelling and record-keeping
requirements.
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 PHARMACISTS
Clinicians can create problems for pharmacists when they:
write illegible prescriptions or prescriptions with unhelpful or unclear
instructions about dispensing requirements, strength, quantity and so on
fail to provide on the prescription a telephone number for contact and the
address of the clinician, information which is legally required
 refuse to accept a telephone call or behave discourteously when asked by
a pharmacist to clarify details of a prescription

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 PHARMACISTS
Clinicians can create problems for pharmacists when they:
 are generally ignorant of the requirement that pharmacists are obliged to be concerned for
patient safety and to ensure that patients understand what a medication is for and how it is
to be used
 make careless comments that can be interpreted as denigrating pharmacists or
undermining their legitimate professional role.
Clinicians who fail to meet their professional responsibilities in their dealings with
pharmacists are open to disciplinary action by HPCZ. Complaints in this area often relate to
rudeness and abruptness and are important because of their potential effect on patient care
and because they reflect poorly on the clinician’s attitude to communication.

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CLINICIAN/CLINICIAN RELATINSHIP
REPORTING IMPAIRED CLINICIAN

Clinicians have as much duty to report an impaired clinician as they do

to report child abuse. Although enormously confrontational, there is no
discretion in terms of avoiding reporting an impaired clinician when
the impairment is clear. If you know that another clinician is not
functioning normally and may be a danger to patients, the privacy of
the clinician is less important than the safety of his patients. This is
true whether the impairment is from substance abuse, a psychiatric
disorder, Alzheimer's emotional disease or an emotional disturbance.
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CLINICIAN/CLINICIAN RELATINSHIP
REPORTING IMPAIRED CLINICIAN contd.

You should report clinicians and students in training to their local supervisor
first; report a resident to his program director or department chair; and report
a medical student to his dean or course director/coordinator or clinical
instructor. You should report attending clinician to the department chair or
division head. If the attending clinician is a self-employed clinician in
private practice, then there is no department chair or division head to which
you can make a report. You should report clinician in the community in
private practice to HPCZ. The key is to go to whoever might have a
authority over that clinician. The lines of supervision are much clear in the
hospital or in medical school, where there are clear supervisors.

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CLINICIAN/CLINICIAN RELATINSHIP
REPORTING IMPAIRED CLINICIAN contd.

You only have duty to report behaviour that affects patient care. If
a clinician goes out to wild parties but there is no detectable
impairment of patient care, this is no something to report. If a
clinician likes to get tattoos, use bad language, and ride in a
motorcycle gang on the weekend, this in not something to report.
Your duty to report is based exclusively on behaviours found to
have an adverse effect on patient care.
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CLINICIAN/CLINICIAN RELATINSHIP
REPORTING IMPAIRED CLINICIAN contd.

The bottom line is that it is your mandatory duty to report an

impaired clinician who may potentially be a danger to patients.
You have the same protections for yourself on reporting as you do
in child abuse, which is that there is no penalty if the report is
found to be untrue as long as the report is made in good faith
without malice.

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CLINICIAN/CLINICIAN RELATINSHIP
CLINICIANS DISAGREEMENTS

If a attending physician disagrees with a clinician’s improper management,

there is little problem because the attending physician has the authority to
overrule the clinician. It is much problematic if the clinician disagrees with
the attending physician. If a clinician finds what may be an error in
management with attending physician, they have to “discuss”, “ confer "or
“try” to reach consensus with evidence based medicine”. If the
discussions are not satisfactory, the bring the issue to whatever is the version
of a higher authority locally. The key words are higher and locally. Do not
go straight to HPCZ without first trying to have a discussion with the
division head or department chair.

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CLINICIAN/CLINICIAN RELATINSHIP
CLINICIANS DISAGREEMENTS contd.

What if the clinician is wrong?

Disagreements between clinicians are handled in much the same way
as reporting an impaired clinician, except that you should always first
pursue discussion with the person with whom you are disagreeing. You
cannot make changes in a patient’s care without the attending clinician
knowing and approving the changes. The attending clinician ultimately
has all responsibility for the patients, and has an absolute right to direct
the care of the patients and know what is going on.
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 CLINICIAN/PATIENT
RELATIONSHIP

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SOM&HS
 BEGINNING AND ENDING THE
RELATIONSHIP
The relationship between a Clinician and patients is a voluntary
relationship that is to be entered freely on both sides. In the same way
that you cannot compel a patient to accept a particular clinician as her/
his clinician without her/his agreement, a clinician cannot be
compelled to accept a patient without his agreement. A clinician must
agree to accept a patient. There is no obligation on the part of the
clinician to accept a patient. This is true no matter what need the
patient has and whatever expertise the clinician may possess.
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 BEGINNING AND ENDING THE
RELATIONSHIP
This is different from a hospital mandate to provide emergency
treatment to anyone who comes to the emergency department.
Hospitals cannot turn anyone away at the door of their emergency
room, if they come seeking care. This does not mean they must
provide continuous care after discharge, but it does mean there is
a national legal mandate for all hospitals to provide emergency
management and treatment of all patients.
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 BEGINNING AND ENDING THE
RELATIONSHIP
Once a patient and clinician have entered into a care relationship
there is far greater complexity in ending that relationship A
physician cannot suddenly end the relationship. He must maintain
the care of the patient until the patient can find an appropriate
alternate source of care and he must give "reasonable notice"'

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 GIFTS FROM PATIENTS
Small gifts from patients of nominal or modest value on the part
of the clinician. This is provided that there is no expectation of a
different form of the therapy or higher level of care based on the
gift. You can accept a cake at Christmas, a balloon on your
birthday, or other tokens of esteem, but not if the patient expects
an extra, or different prescription for something in exchange for
the gift.
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 CLINICIAN/PATIENT SEXUAL
CONTACT
Sexual contact between a clinician and a patient is always inappropriate. It
is unclear if there can ever be a completely acceptable, ethical way to alter
the Clinician/Patient relationship so that sexual contact is acceptable. At the
very least the clinician and patient must mutually agree to end the formal
professional relationship of a clinician and a patient. It is not clear how much
time must elapse between the ending of the professional clinician/ patient
relationship at the beginning of a personal relationship. In our context
clinician/patient relationship does not end consequently sexual contact
between clinician and patient/former patient is inappropriate and
unethical.

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 CLINICIAN AND
SOCIETY

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SOM&HS
 CHILD ABUSE
Child abuse can be physical, sexual or emotional, or involve neglect.
Clinicians are in a position where they can usefully contribute to the
detection of such offences and to the protection of children at risk, but
are more likely to do so if they are aware of their legal responsibility
and maintain reasonable levels of clinical suspicion. Clinicians who
fail to consider the possibility of child abuse in children who present
with repeated or unexplained injuries or illnesses, or with emotional
disturbances, have been subjects of criticism by coroners and HPCZ.
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 CHILD ABUSE
Zambia has enacted laws to provide protection for children from
abuse by placing a mandatory responsibility on clinicians and
others to report suspected child abuse and providing protection
from civil litigation when such reports are made in good faith.
This duty extends also to other health professionals and to
teachers and police. Under the relevant legislation, reporting must
be done immediately as soon as practicable and as soon as
possible.
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 ELDER ABUSE
The same criteria described for child abuse generally apply to elder abuse.
Instead of child protective services, there are adult protective services. Reports
made in good faith can be done without liability to the reporter. The
circumstances with elder abuse are less clear than with child abuse, because the
elderly person is often a still competent adult who may object to the report of the
abuse on the basis that they are afraid of repercussion in the home or the loss of
the home. Nevertheless, must, report elder abuse, and partially breaching the
confidentiality of the patient and family is permissible in the interest of protecting
a vulnerable person.
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 IMPAIRED DRIVERS
Clinicians cannot suspend driving privileges. Only RTSA can
suspend or revoke driving privileges. When a driver is impaired
in any way, the first step is to encourage the driver to report the
impairment, to RTSA. In addition, the clinicians should
encourage all impaired drivers to limit or curtail their driving.
There is no uniform agreement of what, beside seizure disorders
and visual impairment should be reported.
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 CLINICIANS PARTICIPATION IN
EXECUTIONS
A clinician cannot ethically participate in executions in prisons.
This is true even though the execution is legal. Participating as a
clinician in any way in an execution directly opposes the ethical
imperative to preserve life. The clinician's ethical duty to relieve
suffering and to protect life supersedes any ability to participate
in the execution.

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 TORTURE
Clinicians cannot participate in torture at any level. The
knowledge of torture must be reported and opposed as you would
report and oppose elder abuse, child abuse, or an impaired driver.
You may treat those injured by torture once the victims have been
removed from an environment where torture may occur; you
cannot treat injuries to allow patients to become well enough to
withstand more torture.
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 SPOUSAL ABUSE
The ethics and legalities surrounding spousal abuse are somewhat
different from those for child abuse and elder abuse. In the case of
spousal abuse, you are dealing with an adult patient that is generally
competent consequently you do not have the same authority to report
the abuse against the wishes of the victim as you would in the case of
child abuse. Consequently you cannot report abuse to the police or to
anyone else without the express consent of the victim. Encourage the
victim to report or offer counseling.
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 GUNSHOT WOUNDS
Reporting gunshot wounds is mandatory but from a different
perspective than other forms of reporting. The mandatory
reporting of gunshot wounds is based on pursuing a criminal
investigation of the person doing the shooting. Report a gunshot
wound even if the victim objects. The societal need for safety
supersedes the privacy of the patient in the case of gunshots.

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 GIFTS AND INDUSTRY FUNDING
Gifts from industry are to be limited in both type and numerical monetary
value. The presumption is that all gifts from industry are an indirect attempt
to obtain influence from clinicians in terms of their prescribing patterns.
Gifts from industry are acceptable only if they are medical (medical
equipment etc.) or educational (books, training, etc.) in nature.
In addition, the industry may sponsor educational presentations as long as
they do not interfere with the content. Clinicians may accept meals that are
in association with educational experiences such as lectures or conferences.

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 THANK YOU

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