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Wednesday, October 12, 2005

Physician/Patient Relationship BOUNDARY VIOLATIONS

Hmmm...sound like anyone you know????
From Ardvark Blog Kareful of Dr. K series

Gabbard & Nadelson, Professional Boundaries in the Physician/Patient Relationship
There is an inherent power differential between doctor and patient; doctors may exploit this towards their own ends, or patients may assert themselves in attempts to gain power over the physician.


FACTS- Sexual Boundary Violations:

-Occur in all fiduciary relationships, and relationships involving a power differential: lawyers, teachers, clergy, & other health care professionals

-Occur as frequently in the US as in other countries where sexual misconduct has been studied

-Intercourse involving a male physician and female patient is most common


A breach of trust in a professional ("Fiduciary") relationship
May impair physician’s objectivity & judgement
Takes advantage of patient transference
Power imbalance present between physician and patient; the only way for patient to regain power is by enticing physician to violate established morals
Is the patient capable of giving consent? Depending on circumstances, the patient’s consent may be highly influenced by transference and the power imbalance.
There is potential for considerable harm to the patient as a result of such sexual relationships
New Zealand organization recognized 3 catgeories:

-Sexual Impropriety- expressions or gestures that are offensive to to the patient’s privacy & are demeaning

-Sexual Transgression- Inappropriate, sexualized touching that stops short of overt sexual relations.

-Sexual Violation- physician-patient sexual relations, regardless of initiator; includes genital intercourse, oral sex, anal sex, & mutual masturbation

The AMA’s Position:

Romantic or sexual relationships with a current patient are unethical
Romantic or sexual relationships with former patients are not necessarily unethical, but certain aspects must be taken into consideration:
Degree of care: life-saving surgery vs. treatment of a sore throat
Length of care: 5-years of psychiatric care vs. 1-time ER visit
Bottom Line: Relationships with former patients may be ok, but depends on length and degree of care. Don’t have sex with patients you saw for long periods of time or had a massive impact in treatment.


-The patient’s needs should always be the physician’s first priority and supercede the physician’s needs.


- May impair the physician’s ability to focus exclusively on the patient’s well-being.

Ex: A physician orders a chest X-ray on his wife; he finds an opacity that could be breast cancer, but ignores its significance because he would be emotionally devastated if she did have breast cancer.

-May interfere with the physician’s empathy (in relationships involving resentment or dependency)

Ex: A physician finds himself callously delivering bad news to a patient who also happens to be his ex-wife’s divorce lawyer.

-May hinder communication; a patient may not honestly answer physician’s questions or volunteer important sensitive information.

Ex: A woman intentionally doesn’t mention her extramarital affair to her gynecologist because he is close friends with her husband.

-May hinder communication: physician may not ask sensitive questions or confront patients regarding noncompliance or unhealthy lifestyles & behaviors.

Ex: A physician treating his teenage daughter for a UTI neglects to ask her about sexual activity because he assumes she is a virgin.

Ex: A patient admits to using IV drugs for years, but the physician feels uncomfortable counseling him because they are close friends.


Patients may give gifts in order to express their appreciation
Patients may offer to perform services in lieu of payment (bartering)
Barter is a common form of payment in poor or uninsured patients
Bartering is not necessarily a boundary violation; bartering for material goods is probably ok, but physicians probably shouldn’t accept payment in the form of services.
Ex: A patient offers to help file charts in exchange for services; consequently, the patient gains access to other patients’ charts. If the physician is displeased with the work, then there is an additional conflict of interest.

Small, inexpensive gifts are benign boundary crossings; large gifts, however, may represent a patient’s unconscious attempt to bribe the physician ("a secret quid pro quo") or regain power in the physician patient relationship.
Tony Soprano— In one episode of the Sopranos, Tony gave his uncle’s oncologist an expensive golf club, hoping that the oncologist would give Uncle Junior more attention. This wasn’t so much a secret quid pro quo since Tony threatened to beat the oncologist with the golf club if he didn’t pay more attention to Junior.

In another episode, Tony’s psychiatrist considered asking him for his help finding and eliminating her rapist. Accepting services in exchange for treatment is a fishy endeavor…especially when the service in question is murder.


Physician Abuse:

-Keeping patients waiting

-Spending too much time with attractive/charming patients

-Scheduling patients to see you when no one is in the office

Patient Abuse:

-Late for appointments

-Occupying too much of the physician’s time

Old People are pros at occupying a physician’s time with their encyclopedic number of health problems, and stories about their peers who have died. Of course you’ll listen politely, and hope that they fall asleep before you do. During their never-ending stories, make sure to nervously chuckle, frequently check your watch, and pretend to get paged.


-Don’t address unfamiliar patients by first name, or with pet names

-Avoid using potentially offensive slang names (for anatomy, I’m assuming. I think we all know not to use an offensive slang name for a patient by now)

-Never tell a teenage girl that she’s "developing a nice set of breasts" as this could be construed sexually. Instead, say "You are developing normally," or, "Nice hooters!" (j/k)


-Physicians often build rapport by discussing mutual interests, but it can become extreme

-Physicians should avoid disclosing most personal problems to patients, especially for the purpose of comfort or sympathy.

-Excessive self-disclosure is an abuse of the patient’s time: they are paying for you to listen to their problems, not vice versa.


-Physicians should explain the purpose of doing certain elements of the physical exam, especially when examining genitals, breasts, or other sensitive areas.

-If the patient hesitates regarding a procedure, the physician should inquire and assuage the patient’s concerns

-If a male patient becomes visibly aroused during examination, complete the examination without remarking on the erection.

-Use chaperones when necessary:

à Female patient being examined by a male physician

à ANY patient with a known history of sexual abuse

à A patient with extreme anxiety or psychiatric disorder

à Litigious patient

à Any time you (the physician) feels it might be appropriate

Note: Chaperones are useful for helping put the patient at ease, plus they are witnesses to appropriate behavior (or inappropriate behavior if the physician gets frisky) and can protect you from litigious patients.



-Shaking hands

-Holding a patient’s hand when delivering bad news


-Hugs & Kisses

-NOTE: hugging and kissing are innocent greetings in other cultures; patients from other cultures may find this inappropriate

-Be careful regarding physical contact and the abused patient; their perception of the contact may differ greatly from yours

-Some patients may read too much into an innocent hug or kiss

Too Far:

-Back rubs

-Greeting by ass-grabbing (Rene, I’m looking at you)


-Education, including information regarding treatment of sexually abused patients

-Teaching professional conduct in the context of a physical exam

-Teaching Gender & Cultural sensitivity

-Information on the appropriate treatment of sexually abused patients

-Physicians training desensitizes physicians to certain procedures that patients may find invasive or violations of their privacy; developing sensitivity towards these situations is important

-Kick out unscrupulous physicians (the article says "redirect toward other careers")

Anonymous, A Case of Professional Misconduct Or, Confessions of a Doctor who slept with his female patients & staff

Intro Facts:

-Treatment for sexual misconduct exists & is effective (it’s labeled Sexual Addiction)

-There are often warning signs prior to actual sexual misconduct

-Boundary violations occur when the physician places his needs above the patient’s needs

-This author believes that any sexual contact with former patients should be prohibited (but I think he’s primarily referring to psychiatrists & their patients)

-5-15% of physicians in all specialties engage in sex with their patients

Risky behaviors:

-Focusing practice almost exclusively on vulnerable clientele

-Unusual office practices, including seeing patients at late hours

-Practicing when impaired (drunk or high)

-Physician Narcissism: taking one’s importance too seriously

Sexual addiction- sexual misbehavior is often framed as sexual addiction; in fact, it is characterized by some of the symptoms of other forms of addiction:

-Inability to stop the behavior in the face of serious consequences

-Feelings of despair that follow the compulsive behavior

-Ritualized repetition of the behavior for relief

Various authors have developed numerous archetypes for boundary violators; here are the most relevant ones:

Uninformed and Naïve: an individual having difficulty understanding and operating within the professional boundaries

Healthy or Mildly Neurotic: Involves an isolated or limited episode; the physician is remorseful, terminates the relationship on his/her own, and may self-report the misconduct.

Severely Neurotic and/or Socially Isolated: The physician has long-standing emotional problems, depression, feelings of inadequacy, low self-esteem, and social isolation. Work is the center of this person’s life, and all his/her needs are met through work. This physician will foster inappropriate closeness with patients; they may feel remorse by are unlikely to terminate the relationship. They tend to be self-punitive rather than attempting constructive change.

Impulsive Character Disorder: Long-standing problems of impulse control, poor judgement, little remorse or awareness of harm to the victim.

Sociopathic or narcissistic Character Disorder: Deliberate, calculated abuse of patients

Psychotic or Borderline Personality: severely disturbed, impaired reality testing, poor social judgement (hint: physician has drastically skewed perceptions regarding reality, may believe that everyone is in love with him).

Antecedents to Sexual Misconduct (as experienced by the author):

-Over-valuing healing capabilities; belief that he was the only one who could help certain patients

-Spending disproportionate amounts of time with certain patients

-Keeping secrets; intentionally omitting information from the medical chart

-Becoming defensive or possessive about patients with other staff

-Excessive alcohol use


à Time-out: physician believed he could confine the phys/pt. relationship to therapy sessions & keep the romantic relationship out of those sessions

à "It was mutual": patients, especially psych patients, are not necessarily capable of consenting to sexual contact

à "I just give her medication": psychiatrist believed that since he wasn’t administering the psychotherapy, he was ok. He discounted the existing power differential.


-Cognitive-behavioral therapy to decrease inappropriate sexual arousal

-detailed examination of episodes of sexual misconduct

-Education, specifically demonstration of how the misconduct negatively impacted the victim

-Institution of a "Safe Practice" plan following treatment

Indicators for success:

the physician admits guilt & responsibility for misconduct
It is the first intervention the physician has had; if prior interventions have failed, a current one will likely fail
The physician is "caught" in the act (helps motivation)
The physician is not overwhelmed by life problems
The risks of treatment are definable and limited (I have no idea what this is really saying)
Safe Practice Plan:

Physician in question should avoid treating patients to whom he/she may be potentially attracted (for example, the author only treated male patients)
Physician should fully inform his/her staff and colleagues of his history of misconduct
The physician should enlist the assistance of a supervisory team to observe & report misconduct antecedents, or overtly sexual behaviors
Ensure that the physician gets regular feedback from the supervisory team