Case Study 2 Instructions: Please read through the case study below and consider the questions that follow.
Two male physician-colleagues in a group practice are having lunch together when one begins to describe an unusual pattern of meeting with a patient, a 34-year-old woman. The patient has severe ongoing headaches that have been recalcitrant to treatment, and she makes frequent clinic appointments. The physician who sees her describes her as attractive, resembling, he says, his ex-wife. She does not get along with others in the clinic office, however, and has had verbal altercations with the office staff. He believes he can help her and has offered to meet with her at a coffee shop across the street from the clinic for her regular follow-up, so as not to subject her to upsetting encounters, which cause her pain levels to spike. Not long after this lunch, the physician who served as the confidante notices that the ongoing coffee shop encounters are now scheduled at the end of the work day and last longer than a typical clinic appointment. At the two men’s next lunch together, the treating physician shares beach photos of the patient, which he says she texted to him. He mentions that he and she are making plans for a play date, as they are both divorced and have young children. He reports that her headaches appear to be improving, and he is hopeful that his combination of prescribed medication and cognitive behavioral therapy is helping her.
1. Is there a legal duty to report the treating physician’s behavior, and what considerations inform this decision?
2. Is there an ethical duty involved for the colleague who witnessed this behavior, and how are decisions reached regarding what to do?
Questions for case study: Discussion: A “slippery slope” scenario is when the fraying of treatment boundaries is apparent but the behavior by physician has not crossed any legal lines. Because colleagues work together, they may be first to recognize behavior that can serve as a warning that a colleague’s judgment may be off in regard to a particular patient. It is better to address the behavior early before it becomes even more concerning. The ethical duty to report impaired or unprofessional colleagues is bound up in the duty to patients with safety being the crucial issue. Because the patient is not in imminent danger, a possible first step might be to voice concerns about the non-clinical encounters directly to the treating physician. For example, “It is obvious that you care about this patient, but it sounds like her treatment is evolving in a way that she could misunderstand and could end up as a problem for you.” 25 This would give the treating physician an opportunity for self-reflection and correction and also enable the confidante to gauge whether other problems, such as mental-health or substance-use disorders might be causing impairment of judgment. Reporting might next involve a supervisor if the behavior subsequently is unmodified or worsens.
• Prior professional misconduct, including disciplinary and malpractice history • Results of evaluation and assessment and recommendations by evaluating or treating professionals and/or state PHP • Risk of reoffending Range and Variation in Possible Disciplinary Actions If a physician is found culpable, the medical board report will detail particulars of the misconduct and cite which sections of the state Medical Practice Act have been violated. The board will then match the infraction with a broad range of possible sanctions that might include one or more of the actions shown in Table 3. 29 A license to practice medicine is likely to be lost in cases of forced sexual contact. 14 If mitigating factors exist, a license revocation may be stayed in favor of practice limitations or conditions of probation. 1 A physician may be allowed to continue to practice with gender- or age-based restrictions in place, although the FSMB cautions boards only to take this action with a high degree of confidence the physician is not at risk of reoffending. 1 Practice monitors may be required to protect patients and must be properly trained and lack existing relationships with the monitored physician. 29 In addition, the physician may undergo a special evaluation and be required to attend courses on ethics and boundary violations. Physicians found
guilty of sexual misconduct may also face other professional liability claims and criminal charges, when the circumstances warrant them. The FSMB workgroup report states that private letters of warning are inappropriate in cases involving sexual misconduct. 1 When behavior is concerning (e.g., grooming) but does not rise to the level deserving disciplinary action, boards may issue a non-disciplinary letter of education that remains on the physician’s record to facilitate revisiting cases to identify patterns that might pose future risk to patients. 1 Medical boards may choose not to inform law enforcement of violations under certain conditions that include request by the complainant or less egregious misconduct (e.g., inappropriate language). 1 It is important to know that some states and some circumstances require mandatory reporting to law enforcement. There is increased discussion toward requiring state medical boards to report credible allegations of sexual misconduct to law enforcement authorities, particularly if the patient is vulnerable by definition. 6 Only 11 states require medical boards to report sexual violations to police or prosecutors when the victim is an adult. 6,12 Any abuse of a child, minor, or dependent adult must be reported to law enforcement, regardless of complainant wishes. 1 Each person has a responsibility to ensure the safety of children in healthcare settings and to scrupulously follow legal and ethical reporting procedures. 39
Some of the factors medical boards consider in determining the appropriate disciplinary response include: 1 • Patient harm • Severity of behavior and context • Culpability of physician-licensee • Existence of a physician-patient or therapeutic relationship along with its scope and depth • Inappropriate termination of physician-patient relationship • Age and competence of patient • Vulnerability of patient • Number of times behavior occurred • Number of patients involved • Period of time relationship existed Reducing Implicit Bias Medical boards are encouraged to seek training in implicit bias related to gender, gender identity, race, and ethnicity to ensure fair processes in investigations. Areas investigators are asked to be mindful of any personal bias that might affect their judgments, including status as having experienced sexual assault or having been accused of sexual misconduct. 1 The FSMB suggests that public members on state medical boards serve to reduce bias while amplifying the patient perspective.
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