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The importance of keeping it professional: avoiding boundary violations

26 October 2020 | Ruanne Brell, BA LLB (Hons), Senior Legal Adviser, Advocacy, Education and Research, Avant

A UK case involving a junior doctor illustrates the potential for professional and patient harm when a professional boundary is crossed. 

Ms A attended several appointments with Dr C, a psychiatry registrar, at a public clinic in a UK hospital. After one appointment, Dr C met her in the car park. He approached her and they sat in his car and talked for some time. Eventually, Dr C suggested they get something to eat. They went to her home where they ate dinner and drank a bottle of wine, which Dr C had purchased. Dr C left. He phoned her at 2am the next morning and then went back to her house where they had consensual sex. He made no record of his meetings with Ms A, but told a nursing manager he had been on a home visit.

Two days later, Ms A was admitted to hospital after a suspected overdose. Dr C did not disclose his contact with Ms A to the treating team at the time but did later tell a senior clinician that he had visited her at home. He was told to make a note in her file and not to see her again. He made no record.

Eventually Ms A told her counsellor about the encounter and the matter was referred to the UK regulator. Dr C accused Ms A of stalking him and suggested that her psychological condition made her evidence unreliable.

After extensive cross-examination of Ms A, the regulatory board accepted her version of events and found Dr C had committed serious professional misconduct. They concluded he had abused his "special position of trust" with a patient whom he knew to be vulnerable. They were also very concerned by his failure to disclose potentially significant clinical information following her suspected overdose. Dr C's registration was cancelled.

Patient harm and abuse of trust

While this scenario involved a doctor in the UK, the prohibition against sexual relationships with patients is equally strict in Australia. The Medical Board of Australia makes it clear that "There is no place for sex in the doctor-patient relationship …" and this prohibition extends to “consensual” sexual relationships with patients. Sexual remarks, touching patients in a sexual way, or sexual relationships with someone closely related to a patient, such as the parent of a young patient, are also inappropriate.

Any breach of sexual boundaries is considered an abuse of the doctor-patient relationship. It can cause significant and lasting harm to a patient and interfere with their medical care. Patients need to disclose a certain amount of personal information in order to seek medical care, and this creates a degree of vulnerability. Some patients may be even more vulnerable because of factors such as their age, a history of violence or abuse, their physical or mental conditions.

Boundary violation complaints in Australia

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.

The importance of clear boundaries

This case illustrates the way professional breaches can compound once a boundary is crossed. In this case, Dr C's initial breach was compounded by his attempts to conceal the relationship. Withholding clinically relevant information may have exposed the patient to further risk of harm. The regulator also considered his attempts to cast doubt on Ms A's claim, which subjected her to the ordeal of extended proceedings, "reprehensible" and "fundamentally incompatible with registration".

As a practitioner, it is important to establish clear lines you do not cross. If a patient does approach you, be polite, but firm and clear in declining. If you are concerned the patient may be resentful or react badly, it can be helpful to stress that this is a professional issue. You can refer to there being rules for doctors in explaining why it is not possible for you to accept an invitation.  

Inform a practice manager or colleague. They may also need to help you to manage the situation if you need to end the therapeutic relationship with the patient.

Document what has occurred

It is important to make a note of what has happened.

In the patient’s record, this may only be a brief note, being as objective as you can, since the record may be accessed by third parties. For example, this may record details along the lines of:

  • Any inappropriate approach from the patient (e.g inappropriate advance/suggestion by patient).
  • Your response politely declining the approach.
  • Your explanation to the patient that it is not appropriate and unprofessional.
  • The patient’s response (e.g. accepting and understanding or upset).
  • Discussed with practice manager/colleague.
  • Care to be transferred and those arrangements.

You may want to make a separate and more detailed note for your own records, employer or practice along the lines of an incident report. This would outline exactly what you and the patient said, as well as the response from person to whom you reported the incident, and any further developments.

Relationships with past patients

It is never acceptable to have a sexual relationship with a current patient. Relationships with past patients may not be quite so clear cut, however they can still be problematic.

Relationships are more likely to be considered unethical where the patient is vulnerable, or where the treating relationship involved a clear power differential. Patients who were underage when the treating relationship began would be seen as highly vulnerable. Complaints that have resulted in particularly strong condemnation by regulators have involved patients who have mental health issues or addictions, or who are seeking treatment for sexual health issues. The Royal Australian and New Zealand College of Psychiatrists considers sexual relationships with former patients are always unethical, whether or not they are consensual.

While professional and social lives can become blurred, particularly if you practise in a small or rural community, the more separation you can maintain between these roles the better. Fundamentally the questions to ask yourself whether:

  • you would be at all concerned if your colleagues were aware of the relationship; and
  • the relationship is in any way likely to prejudice the patient's care.

If you do find yourself in a situation where you are concerned a line has been crossed, honesty and transparency are the best option from the outset if concerns are ever raised. Ensure that the patient's care is transferred to another practitioner and seek advice from Avant.

Further reading:

Avant factsheet: Boundary issues

Medical Board of Australia’s Guidelines: Sexual boundaries in the doctor-patient relationship

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