Furthermore, it would be grossly unethical to use private information obtained during treatment to coerce a former patient into a sexual relationship under threat of disclosing the information. A physician also often interacts with third parties (e.g., spouses or partners, parents, guardians, and proxies), offering them information, advice, and emotional support. Factors to consider in judging the appropriateness of engaging in sexual or romantic relationships with third parties include the following: 28 • Nature of the patient’s medical problem • Length of the professional relationship • Degree of the third party’s emotional dependence on the physician • Importance of the clinical encounter to the third party and the patient The AMA Code of Medical Ethics suggests that third-party relationships are more troubling when the person is deeply involved in the clinical encounter and in medical decision making for the patient. 28 Physicians should refrain from pursuing such relationships with key third parties if based on the use or exploitation of trust, knowledge, influence, or emotions derived from a professional relationship. BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 1.
The responsibility to set and maintain professional boundaries in interactions with patients lies with the physician. 13,14,30 Because of lack of education or awareness, practicing physicians may encounter situations in which they have unknowingly violated their state Medical Practice Acts through boundary violations. 1 Dubois and colleagues notes that 40% of boundary violations in their study involved inappropriate touching or consensual sex, suggesting an opportunity to remediate ignorance in regard to medical professionalism by developing better insight into one’s behavior and its impact on others. 1,6 One way to do this is ask oneself the motivation for any action that would be considered clinically unorthodox and to know that it is misconduct if it is sexually motivated. Boundary Crossings Some actions with patients may be benign (or thought to be benign) but lie outside of usual clinical practice. Boundary crossings consist of actions that deviate from a physician’s standard practice and represent forays into a “gray zone.” 2 The concept of the “slippery slope” from the field of psychiatry says boundary crossings may progress to boundary violations down the line. Whether a boundary crossing is harmful, neutral, or beneficial can only be assessed within the clinical context. Therefore, it is important to consider the relevance to the patient and the motivation by the physician for any deviation from usual practice.
Maintaining Professional Boundaries Each state’s Medical Practice Act defines unprofessional conduct within that state. Many states have commonalities in examples of unprofessional conduct, which often include: 29 • Alcohol and substance abuse • Sexual misconduct • Neglect of a patient • Failing to meet the accepted standard of care in a state • Prescribing drugs in excess or without legitimate reason • Dishonesty during the license application process • Conviction of a felony • Fraud • Inadequate record keeping • Failing to meet continuing medical education requirements Establishing professional boundaries to prevent sexual misconduct begins with recognizing and preventing workplace sexual harassment, which may range from inappropriate to unlawful. Any sexual harassment permitted within a professional culture risks dire consequences to patients and fosters an unwillingness by bystanders to report misconduct. 1,24 In the case of consensual relationships involving professional colleagues, no supervisory role is appropriate and should be eliminated if both parties wish to pursue a relationship. Firm and enforceable policies around sexual harassment set the tone and culture for professional practices that will extend to respecting and safeguarding patients.
Case Study 1 Instructions: Please read through the case study below and consider the questions that follow.
A 22-year-old college student sought care from her family physician of four years for a suspected urinary tract infection. A diagnosis was made via urinalysis, and antibiotics were prescribed. During the clinic visit, the student mentioned a possible wish for birth control, and the physician suggested she make an appointment for a full gynecological exam. He mentioned that he could check “her equipment” for any problems she might have achieving orgasms and that he could help her performance live up to her “porn star” looks. He was otherwise kind, professional, and attentive to her other clinical concerns, including checking an ankle she had recently strained, suggesting that she continue to elevate it nightly for a week or two and use ibuprofen as needed. The student attended college out-of-state from her hometown and so sought medical care for the first time on her own with this physician. She first saw him at age 18 for treatment of dehydration following a severe case of seasonal flu. At that time, she had found him to be professional and competent. She now felt confused by his statements regarding her purported intimate concerns, which he, not she, had raised.
1. Does the behavior on the part of the physician constitute grooming?
2. What issues are raised in regard to professional boundaries (e.g., sexual impropriety vs. violation)?
Questions for case study:
Discussion: The physician’s comments go beyond grooming behaviors, which might include maneuvering to see a patient after normal clinic hours meant to “test the waters” to see whether a patient will object and/or whether an opportunity for misconduct exists. The inappropriate comments were meant to create an environment of intimacy and were a form a sexual impropriety that may also be a precursor to other, more severe forms of sexual misconduct.
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