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  • Unhealthy relationships with patients

    How to avoid boundary violations

    Having healthy relationships is a key factor in maintaining your health and wellbeing and this includes having good professional relationships with your patients. But be careful that you don’t cross those professional boundaries into more dangerous territory.

    Boundary violations can range from the obvious – engaging in sexual activity with a patient – to other transgressions, such as relationships with someone close to a patient, peer-to-peer relationships or those with other health care practitioners. While crossing these boundaries is not always a disciplinary matter, they may call into question your professionalism.

    Boundary violations can have devastating consequences. Sexual misconduct can create a lot of public and media attention and this can have severe repercussions for your career, your working relationships and your family. A medical practitioner’s reputation is often blemished and patients feel a loss of confidence, it may also be a trigger for other complaints from patients and former patients.

    If you are found guilty of professional misconduct due to a boundary violation, penalties can include:

    • deregistration
    • suspension
    • conditions on registration, such as the need to have a chaperone present during examinations.
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    Reminder from avant-learning-centre

    Factsheet - Why use a chaperone

    Sexual misconduct

    Engaging in sexual activity with a patient, making sexual remarks, touching a patient in a sexual way or engaging in sexual behaviour in front of a patient are all sexual misconduct, regardless of whether the patient consents.

    If another practitioner forms a “reasonable belief” that you have engaged in sexual misconduct, they must report you to the Australian Health Practitioner Regulation Agency (AHPRA), under mandatory reporting requirements.

    The Medical Board of Australia’s guidelines on sexual boundaries state:

    “Good medical practice relies on trust between doctors and patients and their families. It is always unethical and unprofessional for a doctor to breach this trust by entering into a sexual relationship with a patient, regardless of whether the patient has consented to the relationship. It may also be unethical and unprofessional for a doctor to enter into a sexual relationship with a former patient, an existing patient’s carer or a close relative of an existing patient, if this breaches the trust the patient placed in the doctor.”

    But what about relationships with former patients or someone close to a patient?

    For psychiatrists it is misconduct to enter into a sexual relationship with a former patient even though the treating relationship is no longer on foot [3]. For other specialty groups a relationship with a former patient may be acceptable depending on factors such as the duration of care provided to the patient, time elapsed since the end of the professional relationship and the degree of dependence and vulnerability of the patient.

    Sexual activity with a person close to a patient such as carer, guardian, spouse or child of the patient, or the parent of a child patient is also unprofessional.

    If you feel you are at risk of a boundary violation or have overstepped your professional boundaries, seek advice. You can contact Avant’s Medico-Legal Advisory Service or Avant’s Member Support Service for confidential counselling.

    If you receive a complaint alleging sexual misconduct or breach of a boundary issue, do:

    • Ring Avant for immediate legal advice. You will also need to notify Avant in writing
    • Understand that it is perfectly normal to feel angry or upset on receiving the complaint

    Do not:

    • panic
    • ignore the complaint
    • contact the patient involved

    Your first instinct may be to contact the patient to ‘sort things out’, but in most States it is an offence to attempt to persuade the complainant to discontinue the complaint or to take any reprisal action.

    Cautionary Tale

    Case Study

     

    Relationship with a patient's mother

    Dr U was a paediatrician in Private Practice. Although he worked in a metropolitan practice, he was professionally isolated. He commenced a sexual relationship with the mother of a patient which continued intermittently over 3 years.

    He was deeply remorseful for the effect the relationship had had on his patient, her partner and his own family and admitted that his conduct amounted to professional misconduct.The doctor took steps to address the issues that led to the transgression including:

    • Undergoing counselling sessions to discuss the impact of his relationship on the families and to address his underlying motivations for the relationship
    • Consulted a psychiatrist to explore his motivation and weaknesses that led to the inappropriate conduct
    • Approached a colleague to act as a mentor and set up monthly meetings to discuss clinical issues and ethical dilemmas in practice
    • Completed an ethics course
    • Reflected on, and took steps in his practice to avoid a recurrence – such as being more clinical and less involved, avoiding discussing his personal life with his patients, and avoiding physical contact with patients that can be misinterpreted.

    The Tribunal was satisfied that Dr U demonstrated genuine insight and contrition and had taken positive steps to address the issues which allowed the conduct to occur. He was reprimanded, and had conditions placed on his registration requiring ongoing psychiatric treatment and mentoring[1].

    Non-sexual relationships with patients

    Interaction with patients which is not of a sexual nature can still be considered unprofessional. What about inviting a patient to have a coffee or to go for drinks? Each case will be decided on its particular circumstances, so a 50-year-old doctor inviting a 50-year-old patient whom he or she has known for many years to share a coffee if they meet accidentally in a shopping centre is unlikely to attract censure. In contrast a 50-year-old practitioner inviting an 18-year-old patient to have drinks after work is likely to be considered a boundary transgression. It is a step which is much more likely to blur the boundaries between an appropriate doctor-patient relationship and one which is inappropriate.

    We live and work in an age of informality and multiple forms of communication. This can result in inadvertent encouragement of a patient’s feelings. Be careful in your interactions with patients not to blur the boundaries and open the way for transference or misinterpretation. The NSW Medical Tribunal noted in a recent case “while it is important to be empathetic and to listen carefully to the patient, this can increase the chance of blurring of doctor patient boundaries and boundary violations.” [1]

    Working in regional areas can be especially difficult. If the population in the area is particularly small, the opportunities to have usual social contact are reduced and it may be that almost all persons the doctor meets socially, have also at some point been patients. While Tribunals have recognised that these difficulties do exist, they still expect you to take all reasonable steps to avoid relationships with patients.

    Some of the things you need to consider include:

    • Making friends with patients or treating friends as patients can lead to unreasonable patient demands
    • Politely decline invitations from patients to be Facebook ‘friends’
    • Living and working in close rural or cultural communities means you may be invited to social and community events. You don’t need to decline every invitation you receive but do consider the nature of the event before accepting. And, you must always maintain professional boundaries if you choose to attend
    • Accessing patient records for the purpose of making social contact breaches the patient’s right to privacy.

    Cautionary Tale

    Cautionary tale

     

    A patient with anxiety and depression

    A practitioner was treating a patient with anxiety and depression.

    To help her manage her condition he emailed her sound files with music he believed she liked and also pictures of art and other subjects. In reply, the patient opened up and started to discuss her personal life (which in the GP’s rooms would probably have been fine) and asked about his family and other aspects of his personal life. The patient’s sister saw some of the emails and felt the practitioner was grooming the patient for an inappropriate relationship and complained to the Medical Board. When an explanation was given, the Board took no adverse action, but the practitioner could have avoided the stress of a disciplinary process by recognising some of the warning signs. When the patient tried to encourage more personal sharing, the practitioner could have firmly but kindly indicated it was important not to blur boundaries.

    Cautionary Tale

    Case Study

     

    Maintaining professional boundaries

    Avoid situations that may be misconstrued by the patient – for example:

    • Giving a patient a lift home in the car
    • Seeing patients outside the surgery without a clinical reason
    • Telephoning the patient without a clinical reason
    • Having personal transactions with patients, such as lending money
    • Conducting non-emergency consultations outside normal surgery hours
    • Having conversations with patients of a personal nature.


    Medical examinations can be misinterpreted by patients, and they can be left feeling that proper boundaries have been crossed so when conducting examinations:

    • Explain if an intimate examination needs to be conducted and why
    • Explain to the patient what the examination will involve
    • Obtain the patient’s permission before commencing
    • Give the patient privacy to undress and dress
    • Keep discussion relevant and avoid unnecessary personal comments
    • Encourage questions and discussion
    • If you can sense that the patient feels uneasy, offer a chaperone or invite the patient to bring a relative or friend.


    Be aware of your own vulnerabilities:

    • Develop skills in saying ‘no’ whilst maintaining compassion and rapport.
    • Be aware of the impact of isolation and take steps to have as much peer interaction as possible
    • Do not to be seduced by comments that may appeal to your ego ‘you’re the only person who listens to me and understands me.’
     

    References
    • HCCC v Underwood Medical Tribunal of NSW 22.8.12
    • Medical Board of Queensland v Doolan (2001) QHPT 003
    • RANZCP Ethical Guideline number 8