The nine boundary domains identified by Guthail and Gabbard along with some examples of issues or motivations to consider concerning these domains are: 31 1. Role (e.g., is that part of what a doctor does? Are you also a friend, spiritual mentor, other?) 2. Time (e.g., standard vs. special hours, alone in building at end of day) 3. Place and Space (e.g., deviating from usual settings) 4. Money (e.g., reduced fees for which gratitude or other “currency” is expected) 5. Gifts and Services (e.g., set policy regarding max dollar value, perceived obligation) 6. Clothing (e.g., self-expression vs. cultural/ community norms, institutional expectations) 7. Language (e.g., first names, colloquialisms, humor) 8. Self-Disclosure (e.g., rapport, reassure patient, burden patient, patient curiosity) 9. Physical Contact (e.g., handshake standard pre-pandemic, touch on shoulder, hugs) Regardless of intent, physicians should avoid any clinical or nonclinical contact with a patient that could be construed as sexual or romantic. 13 Examples might include any evaluation of a patient outside the usual clinic setting that could be seen as blurring the boundaries between professional and nonprofessional interactions (exceptions might include an emergency or medically-indicated home visit). During clinic visits, expressions of humor should steer clear of sexual innuendo and provocation. Interactions by telephone, e-mail, text, or social media all should reflect the same high standard of professional boundaries. Physicians should be aware that physical contact that may be intended as a comforting gesture (e.g., placing a hand upon a patient’s knee) may be experienced differently by the patient. The American College of Obstetricians and Gynecologists (ACOG) Committee on Ethics issued the opinion that under some circumstances, limited physical contact between a physician and a patient, including a brief hug or holding a patient’s hand, may provide valuable therapeutic support with clear indication that the patient is open to such contact and its duration is appropriately limited. 13 The patient’s age, gender identity, nationality, community norms, and many other factors influence how physical gestures are received. A handshake has been considered standard and expected when good hand-washing practices are observed; 2 however, Covid-19 protocols have shifted practices in this regard. When in doubt, ask the patient. If the patient offers an appreciative hug, it is best to consider one’s own comfort level with the gesture and to respond accordingly. This might entail tactfully deflecting physical gestures that lie outside the clinical context. If a patient initiates inappropriate contact, physicians should separate themselves from the patient, reinforce professional boundaries, and, if feeling unsafe, exit the room and request any needed assistance. 32
Awareness is key to preventing the progression to boundary violations. Physicians are asked to reassess their motivations and to ask the primary question of whether an action that is not within the one’s usual practice is beneficial to the patient and relevant to the patient’s medical care. 2 Physicians are also asked to reflect upon personal vulnerabilities that might motivate instances of self- disclosure, non-clinically-indicated touch, or other crossings of professional boundaries. Questions for self-reflection might include what circumstances might be affecting one’s decision making, including whether one is bored, sick, lonely, recently divorced, or experiencing other life stresses.
The AMA website lists reporting incompetent or unethical behaviors by colleagues among the top 10 ethical issues students should learn in medical school. 35 This requirement goes to the heart of medicine’s long tradition of self-regulation, which calls on physicians to safeguard patients’ welfare. Professional codes of ethics and other statements from medical associations are expressions of self- regulation but lack strong enforceability, being limited to such actions as censure or loss of membership. 23,36 In most jurisdictions, there is also a legal obligation to report physician misconduct. 14 Most states make it a condition of licensure for physicians to formally report to the board of licensure any reasonable basis to believe another licensee has violated any of the board’s regulations. 25 In addition, most states protect from lawsuits those who report in good faith. 25 State Medical Practice Acts and other relevant legislation outline responsibilities in regard to patient welfare. 34 For a good example of the duties incumbent upon physicians, organizations, hospital leaders, medical officers, and medical staff in reporting professional misconduct or incompetence to state medical boards see the document, “Essentials of a State Medical and Osteopathic Practice Act:” https://www.fsmb.org/siteassets/ advocacy/policies/essentials-of-a-state-medical- and-osteopathic-practice-act.pdf. Similar language is included in most state law. However, states vary in how legislation describes the mandatory duty to report with language that may require actual or first-hand knowledge, reasonable cause, or reasonable probability (as distinguished from mere probability) that an action constitutes misconduct. 1 The FSMB suggests the “theme of reasonability” as a guide to reporting colleague actions. Therefore, if “it is reasonable” to believe misconduct occurred, physicians must report the actions to the state medical board and (with some exceptions) to law enforcement. 1 State medical boards also may take disciplinary action against licensed physicians who fail to report misconduct. 1 The Challenge to Report Unfortunately, much misconduct observed among medical colleagues and in learning environments goes unreported, despite the ethical and legal imperatives. A survey of 3504 physicians found that while 96% of respondents agreed that physicians should report impaired or incompetent colleagues to authorities, 45% of respondents had encountered such colleagues and not reported the information. 37 Other data indicate that the patient is nearly always the one to report misconduct, rarely another member of the medical team. 6 Physicians and other healthcare colleagues fail to report misbehavior in the workplace and educational environment for several reasons that include: 1,25 • Moral distress and discomfort with reporting colleagues • Power dynamics that put reporting physicians at risk for professional consequences
A “Slippery Slope” Scenario 2 »
Patient starts addressing you by your first name You start scheduling that patient on Fridays, at the end of the day You share a recent personal crisis with the patient The patient gives a hug at the end of that appointment Weeks later, you accept the patient’s invitation for coffee The relationship moves on to dating and physical intimacy
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Duty to Report State medical boards depend on individuals and entities to submit information pertinent to patient safety to fulfill their mission to regulate medicine in the best interests of patients. Physicians and medical students are ethically and often legally required to report suspected instances of sexual misconduct and patient harm. 1,25,30 Failure to report may be considered professional misconduct and is subject to disciplinary action by medical boards. 14 The FSMB further suggests that when self-regulation fails, state medical boards should be empowered to levy fines against institutions who fail to report egregious conduct, perhaps publicizing the reasons, increasing reputational risk and thus incentive for institutions to report. 1 Many professional organizations (AMA, AAOS, ACOG) as well as state licensing and disciplinary agencies require reporting of sexual misconduct as an ethical standard. 14 The AMA states that responsibility to the patient is paramount and includes the imperative to report physicians engaged in unethical behavior. 33 An FSMB position statement on the duty to report highlights the professional obligation to “do no harm” and the “ethical principle of beneficence.” 34 These obligations encompass preventing direct harm (or circumstances with high risk of harm) to patients and also by removing conditions that would lead to harm. Thus, the duty to report is considered fundamental to fulfilling the principle of beneficence by removing potentially harmful conditions.
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