Although remediation may be appropriate for some misconduct, evidence regarding its effectiveness is limited and recidivism is hard to study. More research is needed in many areas, including group learning experiences, instruction in victim empathy, the effect of adding other interventions to remediation, and how to identify those at an elevated risk of reoffending. 1 Another factor that hampers study is indistinct coding when behavior is reported, and the specific label “sexual misconduct” is recommended over vaguer terms such as “disruptive physician behavior,” “boundary violation,” 1 or “other.” 38 Furthermore, the category “not applicable” in reports to the NPDB has been called “unhelpful, overused, and unnecessary,” perhaps even enabling the non-reporting of serious offenses. 12 Monitoring Physician Behavior Monitoring capabilities and resources to track a physician’s behavior going forward vary among states. A practice monitor (distinct from a chaperone) who is required to be present at all patient encounters or those restricted by gender and age, is one method that might be mandated by a state medical board. 1 Patients must be informed that the practice monitor is mandated as part of a practice restriction. If the patient is uncomfortable with the presence of the practice monitor, they must seek care from a different physician. Patient supporters such as family members or friends also may be present but do not replace a mandated practice monitor. Criteria for practice monitors recommended by the FSMB workgroup include the following: 1 • Formal training in role, including safe and appropriate ways to intervene • A clinical background • Not an employee or colleague of monitored physician • If unknown contact is not available, existing professional relationship is disclosed (helpful if licensed in another health discipline) • No disciplinary history • Submits regular reports to state medical board Guidelines for a Professional Practice A healthcare practice requires strong policies and supporting interventions to end misconduct by physicians. Leadership within the organization is imperative. All parties within the system should understand the organization’s guidance on professional behaviors and the duty to report unprofessional conduct. All members of the team should see role models for this behavior in daily practice. Studies show that physicians can make positive changes given the right feedback and that serious practice violations may be prevented when there is a systematic approach to observation. 38 Peer review can be provided through medical society- sponsored registries of risky, invasive procedures. 38
Solo medical practitioners can receive peer review from afar through use of electronic medical records. 38 Physicians and other colleagues in the workplace, including those in training, should be able to report sexual misconduct “without fear or loss of favor.” 33 The persons reporting must be protected from retaliation (including through whistleblower legislation) 40 and any implication that progress through medical school and training or in promotions or other career advancement might be impeded. 1 Providing channels to remain anonymous while making complaints and during the hearing processes encourages a culture that reports adverse events without fear of retaliation or jeopardy to inter-professional relations. 34 When anonymous complaints are impossible or infeasible, complainants’ identities should remain confidential and physicians with a complaint against them should not contact complainants. 34 Physicians should promote and adhere to strict sexual harassment policies in medical workplaces. 24 The National Academies of Sciences reports that organizational culture that enables and appears to accept harassment leads to behaviors that are typically repeated and harmful to medical students and trainees. 7 A culture that permits harassment extends perceived license to engage in such behaviors, putting patients at risk for dire consequences. 1 Grievance committees should represent diverse colleagues to ensure balanced discussion and decisions in regard to gender identity, age, ethnicity, sexual orientation, profession, and employment status. 24 Committees should make themselves available to those they are charged to serve and be able to enforce the policies they enact. A summary of recommendations to create professional practices with ethical boundaries in place include the following: 8,38 • Educate physicians at every training stage about the enormity of sexual misconduct, how to avoid it, and how to seek help if they are struggling with boundary challenges • Educate the public how to prevent, recognize, and report physician sexual misconduct • Encourage and empower patients who observe wrongdoing to report it and establish standardized processes for doing so • Mandate reporting of observed misconduct by medical colleagues, medical students, residents, nurses, and others in the workplace and establish standardized processes for doing so • Institute necessary measures to prevent reprisal against individuals who report misconduct • Investigate credible complaints in a timely manner, balancing concerns for privacy with need for transparency • Recognize that sexual harassment is strictly prohibited • Never tolerate behavior that threatens patients or creates a hostile workplace
• Conduct physician evaluations with objective data comparing them to peers or 360° (multisource) evaluations from diverse stakeholders (e.g., colleagues, patients, caregivers, family members, supervisors, peers, allied health co-workers, trainees) • Provide chaperones by default when an intimate examination is medically indicated • Institute a systematic approach to peer review and oversight of group practices • Warn all members of the healthcare team not to submit false or malicious reports or expect disciplinary action in response to any frivolous claim. 1 A change in culture is achieved by making failure to report a professional liability in itself, one that is well understood to be unacceptable and liable for sanction. 1 Any false or frivolous reporting, whether driven by competition, personal animosity, or some other reason, should be met with stern disciplinary action. 1 The goal is to make the duty to report a core component of the medical profession rather than a burden that falls on the shoulders of a few. Guidelines for Basic and Intimate Examinations Good professional conduct starts with respectful, clear communication. Communication should occur throughout any examination that takes place without general anesthesia and should convey: 39 • The medical necessity • What the exam/procedure will involve • Any discomfort the patient might experience • Expected benefits • Potential risks • Any findings For intimate examinations, it is especially important to communicate clearly to explain the parameters of interaction for physician and patient and minimize potential misunderstandings of the physician’s actions. 39 Misunderstandings arise when sexual misconduct has occurred but the patient does not recognize it as such, as well when a patient perceives an interaction as sexual or romantic when the physician had no such intent. 13 Interactions that require sensitive physical examinations and disclosure of private information must be respected as times of intense vulnerability for patients. Respecting a patient’s dignity during intimate physical examinations requires providing a comfortable and considerate atmosphere. Some best practices include the following: 13,41 • Provide appropriate gowns • Provide private facilities for undressing • Use draping sensitively • Clearly and appropriately explain components of the physical exam • Perform only with the patient’s consent • Perform with minimum amount of physical contact to inform diagnosis and treatment • Offer the patient the opportunity to ask questions or raise concerns about any element of the exam
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