Boundary Issues

Quick guide

• Establish clear boundaries with patients and work within those boundaries.
• Communicate clearly and without ambiguity if those boundaries are challenged.
• It is never acceptable to have a close personal and/or sexual relationship with a current patient.

Implications of boundary issues

Crossing a professional boundary can lead to significant personal, professional, and financial issues. The Medical Board of Australia regards allegations of breaching professional boundaries very seriously. The Board’s guidelines clearly state “There is no place for sex in the doctor-patient relationship, either in the guise of a ‘consensual’ sexual relationship, or in the form of sexualised comments or behaviour, or indecent or sexual assault.”

The power imbalance implicit in the doctor-patient relationship has an impact on the relationship dynamic that you may not contemplate until a boundary is crossed. Irrespective of your (or your patient’s) intentions, blurring the boundaries of a therapeutic relationship can cause the patient psychological harm and interfere with their medical care. By entering into a personal relationship, regardless of intentions or consent, you cross the professional boundary.

Setting and maintaining clear boundaries

Crossing a boundary within a doctor-patient relationship rarely involves a drastic change in behaviour, but more commonly results from a gradual blurring of professional and personal roles. To prevent this, it is important to establish clear lines you do not cross.

Be wary of becoming overly familiar with your patients. Keep social and professional lives separate. If a patient attempts to connect with you outside the professional environment, invites you to a social event or tries to connect via social media it would be wise to politely decline.

If you practise in a rural or small community, professional and social lives can become blurred. This can be problematic, particularly if there is no other doctor you can refer patients to. Reinforcing your professional role, for example by insisting patients make an appointment to see you for medical advice rather than approaching you socially, will help maintain the line between personal and professional.

For more information please see Avant’s factsheet – Treating family members, friends or staff.

It is important to pay attention to your own stress levels and risks. Having relationship problems, feeling personally or professionally isolated, being under stress or unwell may make you more vulnerable to boundary breaches. Being alert to this risk may help you manage it.

Notice if colleagues comment on your behaviour. Are you changing your normal practices with one patient, e.g. scheduling more appointments than necessary or agreeing to see them outside normal hours?

Other unacceptable behaviour

The obligation to maintain professional boundaries can be breached not only by sexual activity. A range of other behaviours may constitute a breach, including sexual remarks or touching patients in a sexual way, or a sexual relationship with someone closely related to a patient such as the parent of a child.

Conducting a physical examination that is unwarranted and not clinically indicated or when the patient has not consented to it may constitute sexual assault. This includes conducting or allowing others, such as students, to conduct examinations on anaesthetised patients when the patient has not given explicit consent to the examination.

Avoiding boundary issues in clinical care

The doctor-patient relationship relies on trust and good communication. Misunderstandings in clinical care can occur through poor communication and an incomplete explanation. Such misunderstandings can lead to patient complaints, for example of inappropriate touching.

If you need to examine a patient, explain clearly and fully what you need to do and why it is necessary. When stating you need to complete a skin check, for example, make it clear to the patient that you will be looking at all their skin, so they will need to disrobe, and that you may have to touch or move some parts of their body.

Consider offering to have an observer present during an examination, especially during an intimate examination; if a patient appears particularly uncomfortable/reluctant/distressed; or if you are uncomfortable. For more information please see Avant’s factsheet – Observers: chaperone, protect and reassure.

What if a patient approaches you about a personal relationship?

If a patient approaches you:

• Give a firm and clear no, explaining it is unethical for you to enter a relationship with a patient. It is important not to be ambivalent or encouraging.
• Document what has happened in the patient’s medical record, remembering that it may be accessed by third parties or you may need to rely on it (e.g., before the Medical Board or in a court case) if a complaint is made against you.
• Immediately inform a senior colleague such as a senior partner/practice principal, supervisor or practice manager.

Patients may develop feelings of resentment if their advances are rejected. It may be helpful to reinforce that this is a professional issue – consider referring the patient to a colleague who can explain impartially why professional boundaries are essential in doctor-patient relationships.

Be especially careful of the patient who tries to seduce you. Considering yourself the victim is no defence. You are expected to refuse the approaches of a patient. This extends to the parent of a young child who is a patient.

Declining a patient’s approach may mean you also need to end the therapeutic relationship. This may not always be necessary but consider whether it would be in the patient’s best interests to transfer their care to a colleague. For more information please see Avant’s factsheet – How to end the doctor-patient relationship.

Relationships with patients

It is never acceptable to have a sexual relationship with a current patient.

You need to immediately transfer the care of the patient to another practitioner and immediately seek advice from Avant.

Relationship with a former patient

A relationship with a past patient is a less clear-cut situation, but extreme caution is necessary. Each situation will be judged on its circumstances. For example, a one-off consultation for treatment of a non-serious condition does not usually involve a doctor-patient relationship at the same level as the ongoing care of a chronic condition. The time that has passed since the doctor-patient relationship existed will also be a consideration.

A personal relationship is more likely to be regarded as unethical if the pre-existing doctor-patient relationship involved a clear power differential, for example a long-term treatment relationship where the patient has a mental health condition and has required counselling and support. The Royal Australian and New Zealand College of Psychiatrists will not countenance a sexual relationship with a former patient under any circumstance. A personal relationship is also likely to be regarded as unethical if the treating relationship began when the patient was a child.

The patient’s capacity to consent to a relationship may also be impaired if their judgment or decision-making ability is compromised. For example, the patient may have previously been the subject of sexual abuse or domestic violence.

If you are contemplating a relationship with a patient it is important to ensure, and document, that the professional relationship has been transferred to another practitioner who is aware of the situation and can ensure the patient has adequate support systems in place.

Other boundaries – conflicts of interest

Blurring of professional boundaries may also occur if a doctor engages in commercial transactions such as business dealings or marketing products to patients. While these are less common than transgressions relating to inappropriate relationships with a patient, they may lead to investigation and sanction by regulators.

If there is a potential conflict, for example, if you refer a patient to a facility or service in which you have an interest, you should always declare your interest.

Behaviour of a colleague

Sexual misconduct is one of the four criteria for mandatory notification to Ahpra. Sexual misconduct includes sexual activity, sexual remarks or touching patients in a sexual way.

You are required to make a mandatory notification if, in practising your profession, you form a ‘reasonable belief’ your colleague is engaging in sexual misconduct in connection with their practice. If you do not report notifiable conduct to Ahpra and it is later determined you should have, you may be also subject to disciplinary action. For more information please see Avant’s factsheet – Mandatory notifications about health practitioners.

Additional resources

Medical Board of Australia’s Sexual boundaries in the doctor–patient relationship is essential reading for every doctor and medical student.