Boundary Violations by Medical Practitioners
Boundary violations occur when a doctor behaves in an unprofessional and untrustworthy manner by misusing their power in the doctor-patient relationship. This may result in harming the patient in some way. I guess many of us would have trans gressed at least one such boundary such as treating family members. The following are examples of boundary violations:
Examples of practitioner-patient boundary breaches include
- Having a personal and/or sexual relationship with a patient (even a former patient)
- Treating family members
- Entering into a business venture with a patient.
- Lending or giving money to a patient.
- Friendships with patients on social media websites.
- Seeing patients socially
- Disclosing confidential or personal information about oneself
So what is so damaging to patients subjected to such violations?
The concern is that violations destroy the implicit trust enjoyed between a doctor and his patient .Where the boundary violation involves sexual exploitation of a patient the consequences are akin to the effects of incest whereby the patient may develop intense shame & guilt depression, post traumatic stress disorder suicidal ideation,
substance abuse ;relationship breakdown and poor work performance.
The quantification of these effects is largely unknown however one study of psychotherapists who breached sexual boundaries with their patients only 17% of victims made a complete recovery.
The effect on the Accused can include deregistration ;loss of income and financial ruin and adverse media publicity. Medical indemnity organisations are not obliged to support the Defendant in cases of criminal charges.
Reports of the sexual abuse of patients reinforce public perception that Medicine as a profession is not meeting its obligations and that doctors are more interested in meeting their own needs rather than those of their patients.
Who are the doctors who violate professional boundaries?
A study by Elkin et al 2011 (MJA 194 (9):452) demonstrated that male Australian doctors were responsible for 80% of disciplinary cases. Obstetricians and gynaecologist predominated followed by psychiatrists .
The three main breaches were sexual misconduct (24%);unethical prescribing (21%) and inappropriate medical care (20%).
The underlying reason for such boundary violations is rarely mental illness but more commonly severe unsupported mental stress in the practitioner and occasionally innate predatory behaviour by the practitioner.
At Risk Patients
Patients with a prior history of sexual abuse are key risks for boundary violations. One study by Quadrio ,1996 of sexually abused psychotherapy patients found that two thirds were victims of previous sexual abuse.Patients with dependent personalities or borderline personality disorders are also at risk.
Defensive Medicine
The best means of defence is to ensure that chaperones are present in consultations with risky patients (at least). A questionnaire has been developed to identify risky medical practitioner behaviours at an early stage.
Questionnaire
Have you accepted for treatment individuals known to be referred by a current or former
patient?
Do you tell patients personal things about yourself in order to impress them?
Do you take great pride in the fact that such an attractive, wealthy, powerful or important patient is seeking your help?
Do you disclose sensational aspects of your patient’s life to others (even when you are protecting the patient’s identity)?
Do you accept gifts or bequests from patients?
Do you join in any activity with patients that may serve to deceive a third party (eg, insurance company)?
Do you ever use information learned from patients, such as business tips or political information, for personal gain
Do you make exceptions for your patient because you are afraid she/he will otherwise become extremely angry or self-destructive?
The clear message from Epstein et al ,1990 is that answers in the affirmative require a reappraisal and changes to that practitioner’s relationship with the patient. That may require professional hep and advice. MDO’s are there to assist with such issues.
Relationships with former patients
Whilst there is considerable doubt in the minds of many practitioners that relationships are unethical the Medical Board of Australia warns that power imbalances may persist long after the professional relationship has ended.
In summary violation of professional boundaries erodes the trust between doctor and patient; it reduces the objectivity of medical practitioners in treating a patient;. In the public perception, accounts of such breaches of professional boundaries diminish confidence in the medical professional and increases the risks that patients will be deterred from seeking medical care, permitting intimate examinations or sharing deeply personal information, because they fear potential abuse.
If there is a possibility that sexual boundaries could be breached, or that the doctor may not remain objective, the doctor should transfer the patient’s care to another doctor. This should be done sensitively so that a potentially vulnerable patient is not further harmed.
Epstein RS, Simon RI. The Exploitation Index: an early warning indicator of boundary violations in psychotherapy. Bull Menninger Clin 1990; 54: 450-465
- Further Reading: Quadrio C. Sexual abuse in therapy: gender issues. Aust N Z J Psychiatry 1996; 30: 124-131.
- Kluft RP. Treating the patient who has been sexually exploited by a previous therapist. Psychiatry Clin North Am 1989; 12: 483-500.
- Luepker E. Effects of practitioners sexual misconduct: a follow-up study. J Am Acad Psychiatry Law 1999; 27: 51-63.
- Galletly CA. Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation. Med J Aust. 2004 Oct 4;181(7):380-3. doi:
- 10.5694/j.1326-5377.2004.tb06334.x. PMID: 15462658.
 "Dr Mike O'Connor")
Author:Dr Mike O'Connor| Tags:Other |
