Boundary violations in small community ends in allegations of sexual assault and cancellation of GP’s registration

When boundaries between personal and professional are crossed , doctors can find themselves in difficult positions, with their judgment compromised, and all aspects of their care coming under question – as this case from regional Australia illustrates.

Prescribing

Dr M was a GP in a regional area. Ms A was a patient of the practice where Dr M worked, and consulted Dr M for lower back pain. Dr M prescribed her oxycodone and naloxone. At a later consultation he diagnosed her with ‘acute mania’ and prescribed anti-psychotic medication (Seroquel), which he later changed to olanzapine.

Several aspects of his care were found by the tribunal to be significantly below the standard reasonably expected of a practitioner with similar training or experience including that he:

• failed to undertake an appropriate socio-psycho-biomedical assessment prior to prescribing drugs of dependence
• failed to take an appropriate history or conduct adequate physical examination prior to prescribing anti-psychotic medication
• failed to conduct appropriate on-going clinical reviews of Ms A while she was taking the medication
• failed to advise Ms A of the risks of the medication
• changed Ms A’s prescription of anti-psychotic medication with no clinical indication and without an adequate assessment
• failed to adequately account for the effects of the prescribed medications on Ms A’s mental health or consider the fact that they might be causing/contributing to her depression and other symptomatology.

Dr M also treated Ms A’s daughter. He was criticised for failing to take an adequate medical history, or conduct an adequate medical assessment of Ms A’s daughter, and for failing to follow up. Dr M also prescribed medication contra-indicated for children to Ms A’s daughter when she was under 12 years of age.

Boundary violation – personal relationship

Staff at the practice became concerned about the number of appointments Ms A was making with Dr M and that she appeared to ‘dress up’ for appointments. They noticed that Ms A would often be seen near the practice during lunch hours and after work. A colleague suggested to Dr M that he terminate the treatment relationship.

The tribunal accepted Ms A’s evidence that during their consultations, Dr M disclosed personal information to Ms A about his wife (from whom he was separated) and daughter.

The tribunal noted Dr M’s evidence that in a small community, doctor and patient would often see each other locally and that it could be easy for patient relationships to blur into friendships. However, Dr M was obliged to maintain professional boundaries and not disclose intimate details of his personal life.

The tribunal also agreed Dr M had acted inappropriately in terminating the doctor-patient relationship, apparently so that they could be friends. Ms A was suffering from an acute illness at the time Dr M terminated the treatment relationship and Dr M failed to appropriately assess whether it was safe to do so, or ensure she had adequate ongoing medical care.

Boundary violation – sexual encounter

Dr M conceded that after terminating the therapeutic relationship he met Ms A on several occasions in the local community. They began to exchange messages via social media and met socially.

Dr M admitted that he had invited her to his home and told her to park away from his house.

The evidence was unclear as to what occurred. Ms A reported that he had sexually assaulted her after spiking her drink. Dr M denied any sexual contact.

While the tribunal was unable to determine whether a sexual assault had occurred, it accepted that there had been a breach of sexual boundaries. The patient was vulnerable, and her behaviour may have been affected by drugs or medication. The evidence indicated she had suffered great distress from the encounter.

Medical record-keeping and documentation

Other aspects of Dr M’s care were criticised including that:

• His records for Ms A were generally inadequate and did not provide sufficient information about his assessment or diagnosis to allow another practitioner to continue care.
• He failed to record any advice that he gave Ms A about the medications prescribed.
• When referring Ms A to a psychologist he failed to provide information about her medications or relevant clinical details such as her history of sexual abuse and marijuana usage.
• He did not record adequate notes of his treatment of Ms A’s daughter.

The tribunal found that Dr M’s conduct constituted professional misconduct.

Dr M’s registration was cancelled for 12 months.

It is never appropriate to engage in a sexual relationship with a patient.

Particularly in rural areas or small communities, the line between professional and personal lives can become blurred. However, it is important to take steps to maintain professional boundaries.

Avoid connecting with patients via social media.

If a professional relationship appears to be crossing a line, you may need to end the therapeutic relationship. However you must consider the patient’s best interests, transfer care carefully if necessary, and ensure the patient has adequate support systems in place.

Blurring boundaries can also mean your professional judgment and objectivity is compromised. If you ever need to provide treatment to someone with whom you have a close personal relationship, document your treatment carefully and refer to another practitioner as soon as possible.

Never prescribe or administer drugs of dependence or psychotropic medications to a family member or someone with whom you are in a close personal relationship except in emergencies.

Avant factsheet – Boundary issues 2020

Avant factsheet – Treating family members, friends or staff

Medical Board of Australia Guidelines – Sexual boundaries in the doctor-patient relationship

Medical Council of NSW – Guideline for self-treatment and treating family members

For medico-legal advice, please contact us on nca@avant.org.au or call 1800 128 268, 24/7 in emergencies.