• Dozens of men who filed suits against Ohio State University alleging that former wrestling team doctor Richard Strauss, MD, sexually abused them under the guise of medical examinations • More than 200 women who alleged that George Tyndall, MD, the longtime campus gynecologist at the University of Southern California, assaulted them during their appointments, prompting a grand jury investigation • More than 150 women, many minors at the time, who testified to being sexually abused by former USA Gymnastics team doctor Larry Nassar, DO, at Michigan State University As important and timely as this topic is, it is rarely and inadequately covered in medical training. Historically, psychiatry is the field with the most attention paid to professional boundaries regarding patients, but the need is pressing for more formal education that occurs earlier within the framework of broader clinical practice. 1,2 For example, a 2007 search of the University of Vermont College of Medicine’s curriculum revealed a dearth of teaching on the concept of professional boundaries. 2 Furthermore, although maintaining professional boundaries begins with respectful communication, which is particularly important when conducting sensitive exams, clinical communications skills receive limited curricular time in U.S. medical schools and even less so for practicing physicians. 5 In recognition of these deficiencies the FSMB workgroup called for education beginning in medical school and residency and continuing throughout the life of a physician’s (or other healthcare professional’s) career. 1 At minimum, physicians and medical students should: 1,6 • Know what constitutes appropriate physician- patient boundaries • Identify and avoid common and potential consequences to both the patient and the physician when professional boundaries are not maintained • Know what defines physician sexual misconduct • Learn the prevalence of physician sexual misconduct and be encouraged to remain vigilant and report it • Be educated regarding the degree of harm patients experience as a result of sexual trauma Physicians require skills in self-monitoring and self-reflection as well in enacting and enforcing practice policies to ensure sexual misconduct is prevented, detected sooner, stopped from recurring, and reported to the appropriate regulatory and legal authorities without fear of repercussions from colleagues or superiors. Training or review is also necessary on how to initiate and conduct sensitive examinations with patients and the communication that is required as a component of such examinations. This CME activity presents important information to help physicians understand and
maintain professional boundaries and appropriate relations with patients. These skills are aimed at improving outcomes for patients, facilitating ongoing practice-based learning, and providing a framework for risk management. Prevalence of Physician Sexual Misconduct It is known that sexual harassment is common in academic medicine and in healthcare work environments. 7 However, the prevalence of sexual misconduct or assault experienced by patients from the physicians entrusted to care for them has not been well studied. 6,8 Prevalence data are based on disciplinary actions by state medical boards or federal agencies or on self-reported anonymous surveys (Table 1). 9 Anonymous surveys indicate the problem is more widespread than would be inferred from disciplinary actions alone. Sexual misconduct is among the most common reasons healthcare professionals are disciplined by medical boards. 6,10 Data from past decades show that 761 physicians were disciplined for sex-related offenses from 1981 through 1996. 11 In 1994, the year with the most reports, 5.2% of all orders were sex related, and 0.02% of 621,129 practicing physicians in the country were disciplined for sex- related offenses. 11 Although few physicians were disciplined, reports of offenses were increasing and incidents were relatively severe, involving patients 75% of the time and including sexual intercourse, rape, sexual molestation, and sexual favors for drugs. 11 Most alarming, “a substantial proportion” of offenders were allowed to continue or return to practice. Because offenders often repeat their misconduct, many patients can be affected over years or even decades. More recent reports in media outlets have led to increased public awareness of the scope of the problem. In 2016, the Atlanta Journal-Constitution published a six-part series on doctors and sex abuse. 12 Reporters examined more than 100,000 disciplinary documents from across the country, eventually identifying more than 3,100 doctors accused of sexual infractions who were publically disciplined since January 1, 1999. Of those sanctioned, more than 2,400 of the violations clearly involved patients. The investigation found that about 70% more physicians were accused of sexual misconduct than were classified as such in the public version of the National Practitioner Data Bank (NPDB), which tracks complaints against physicians. 6,12 Furthermore, the reporters identified an additional 450 physicians from allegations during 2016 and 2017. 13 When self-report by physicians is anonymous, the rates of reported violations are higher than those pulled from disciplinary actions. While a literature review published in 2009 reported a rate of approximately 1.6% of U.S. physicians disciplined for sexual boundary violations with patients, when the same report combined self-report survey samples, closer to 6.8% (257 of 3758) of respondents admitted to such boundary violations. 9
Introduction Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. ~Hippocratic Oath (translated from 1923 Loeb edition) Trust is implicit and imperative in the physician- patient relationship. From the Hippocratic Oath to the American Medical Association’s (AMA) Code of Medical Ethics, members of the medical profession are charged to give medical care that is competent, compassionate, and respects human dignity and rights. AMA Core values include the ethical responsibility to place patient welfare above the physician’s self-interest. 3 When care is disrupted by sexual misconduct on the part of the physician, repercussions are severe and ongoing. The trauma experienced when physicians cross a line endures, harming patients’ mental, psychological, emotional, and physical health. 1 Repercussions extend to families, communities, and the wider public. 1 Targeted patients are known to refrain from seeking necessary medical care down the line with associated implications for morbidity and mortality. Thus, sexual violations committed by a minority of practicing physicians undermine the integrity of the entire medical field. 1 Efforts are underway to examine the extent of physician misconduct and to scrutinize current practices of state medical boards and professional regulatory authorities. A workgroup formed by the Federation of State Medical Boards (FSMB) reviewed available data on sexual misconduct regarding incidence and severity of behaviors, disciplinary actions, and barriers to reporting. 1 Additionally, the workgroup scrutinized and examined how professional culture influences willingness to report physician impropriety. According to the workgroup report published in May 2020, physician sexual misconduct is underreported by patients and medical professionals in the workplace, and shared efforts are necessary to enact widespread cultural and systemic changes. 1 Calls for more accountability come from many quarters. The #MeToo and Time’s Up movements – and the accompanying societal attention -- have grown into advocacy and victim support networks that reach into every strata and corner of society, including the physician’s exam room. Media accounts highlight not only egregious misconduct but the organizational complacency that failed to halt it. Examples published on MedPage Today include: 4 • 17 women who sued Columbia University and its affiliated hospitals claiming the institutions concealed known sexual assaults during office visits by Robert Hadden, MD, a former obstetrician-gynecologist at New York- Presbyterian
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