A slippery slope: avoiding boundary violations

An experienced general practitioner was recently reprimanded, and his registration suspended by the regulator over an inappropriate relationship with a patient. The case illustrates the way in which boundaries can gradually become blurred and compromise the therapeutic relationship.

Dr K had been treating a patient for nearly two years for various physical and mental health issues. He had referred her to a psychiatrist who diagnosed a major depressive disorder. She declined to return to see the psychiatrist but continued to attend Dr K, who became increasingly concerned about her mental health and apparent suicidal ideation. At one point, Dr K gave her his personal email address in case she needed to contact him. She began to email him at home, primarily to discuss her mental health. She declined to see another therapist and insisted she only sought a therapeutic relationship with Dr K. Dr K's notes during this period referred to concerns about boundary issues. However, he occasionally hugged her during counselling consultations and gave her a gift on her birthday. Eventually, they commenced a sexual relationship, which continued for over 18 months and ended when the patient left the area. The relationship was subsequently discovered. Dr K agreed to consult a psychiatrist and self-notified to the regulator.

The regulator determined, and Dr K accepted, that his behaviour amounted to professional misconduct.

Professional and patient harm

Although practitioners may never have intended harm to a patient and may believe the relationship is consensual, the Medical Board of Australia makes it clear that “there is no place for sex in the doctor-patient relationship …”. The prohibition extends to 'consensual' sexual relationships with patients. Sexual relationships with someone closely related to a patient, such as the parent of a young patient, are also inappropriate.

The Board views any breach of sexual boundaries as an abuse of the doctor-patient relationship, warning that it can cause significant and lasting harm to the patient and interfere with their medical care. In order to seek medical care, a patient must disclose a degree of personal information, which creates a degree of vulnerability. This means the doctor-patient relationship necessarily involves a power imbalance. Some patients may be even more vulnerable due to factors that can increase the power imbalance and potential for harm (for example, their age, a history of violence or abuse, their physical or mental conditions).

Boundary violations can also have significant personal and professional consequences for practitioners. A study recently published in the Medical Journal of Australia examined allegations of sexual boundary violations notified to Australian Health Practitioner Regulation Agency (Ahpra) and NSW Health Professional Councils Authority from 2011-2016. Allegations involving sexual relationships were less common than allegations of sexual harassment or assault. However, just over one-quarter of all allegations involved a sexual relationship. General practitioners were among the specialties where notifications regarding sexual relationships were higher than for other groups of practitioners. The study also reported that regulatory sanctions were imposed in one-third of cases.

In Avant’s experience, medical regulatory bodies take allegations of a breach of sexual boundaries very seriously.

The importance of clear boundaries

Boundary violations may result from a gradual blurring of personal and professional roles and do not necessarily arise from a specific event or dramatic change in behaviour. As a practitioner, it is important to establish clear lines you do not cross.

While professional and social lives can become blurred, especially if you practise in a small or rural community, the more separation you can maintain between these roles the better.

This may involve reinforcing your professional role.

You should ensure that all professional contact is through the practice and that patients always make an appointment for medical advice rather than approaching you in public or at social events. Avoid encouraging patients to contact you at home or on your personal phone or email account. Limit the amount of personal information you share with patients. It is advisable to politely decline invitations from patients to connect socially or on social media.

As outlined by the Medical Board, doctors should avoid treating family, friends or staff except in an emergency. Wherever possible, refer them to a colleague or another practice for their ongoing care.

Be aware of your own wellbeing

Experiencing other personal or professional issues, being unwell or under stress may make you more vulnerable to errors of professional judgement in relation to boundary violations. For this reason, it is important to pay attention to your own wellbeing and be aware of potentially problematic situations.

Professional isolation can also be a risk. There may be warning signs early on when a therapeutic relationship begins to be compromised. Having supportive colleagues to refer to, particularly someone you trust to let you know if they see changes in your behaviour, can help avoid the situation deteriorating.

And if you are concerned about your own situation, or that of a colleague, you can contact us on 1800 128 268 or seek help from one of the doctors' health advisory services.

Further reading:

For more information please see:

• Avant’s factsheet on boundary violations
• Avant’s factsheet on treating family members, friends or staff