Overview
This lecture covers professional boundaries in the doctor-patient relationship: what they are, why they exist, and how they are maintained or breached. It moves from a definition of boundaries and the continuum of professional behaviour, through inappropriate patient sexual behaviour and how to respond to it, into the Otago reporting systems for professional concerns, and then through three recurring boundary problems: receiving gifts, treating family members and yourself, and sexual relationships with patients. It closes with why boundary violations happen and what professional supports guard against them.
Professional boundaries: definition and purpose
Professional boundaries are the parameters that describe the limits of a fiduciary (trust) relationship. They imply distance, respect and safety, and they take the form of rules and guidelines about interactions with patients.
Why they are necessary:
- Protection of both doctor and patient
- Safety and predictability
- Respect
- Autonomy
- Privacy
- To facilitate and protect the patient-doctor relationship
- To maintain objectivity and clinical competence
The professional context is set by the Code of Professional Conduct for Medical Students at the Universities of Auckland and Otago: professional responsibilities arise from increasing involvement with patients, whānau and the wider community. Learning medicine in Aotearoa/New Zealand carries an obligation to uphold Māori rights under te Tiriti o Waitangi, and New Zealand’s position in the Pacific region and its formal relationships with Pacific Island nations require a commitment to Pacific peoples. Health professionals must strive for equitable health outcomes for all, particularly Māori and Pacific peoples. Patients and whānau place significant trust in the profession and in those learning to be a doctor; whenever you meet people you represent the Medical School, the University and the profession, and your behaviour both within and outside the clinical environment should uphold the profession’s reputation.
The continuum of professional behaviour
Every clinician-client relationship can be plotted on a continuum with three zones, adapted from the National Council of State Boards of Nursing (2004). Running left to right along a single line:
- Disinterested / neglectful - under involvement
- Therapeutic relationship - the zone of helpfulness
- Boundary violations - over involvement
Both ends are failures; the therapeutic relationship sits in the middle.
Inappropriate patient sexual behaviour (IPSB)
Definition: “Any verbal or physical act of an explicit or perceived sexual nature, which is unacceptable within the social context in which it is carried out.”
It includes staring, gestures, romantic gifts, suggestive remarks, propositions, genital exposure, unnecessary touching or physical proximity, threats and sexual assaults.
Prevalence: a study of physiotherapists found 84% experience this over their career (Boissonnault et al., 2017, Physical Therapy 97(11), 1084-1093).
Risk factors
- Fewer years of clinical experience
- Working with those who have cognitive impairment
- Being a female student or staff member
- Treating male patients
Causes
Unintentional:
- Influence of drugs, or illness affecting behaviour or judgment (e.g. CVA, TBI, delirium, psychosis)
- Lack of insight, poor ability to moderate behaviour, impulsivity, poor response to stressors
- Not being aware of the professional boundaries between patient and clinician, which may mean the clinician has not set those boundaries well
Intentional:
- Attempting to be intimidating in order to regain power
- Wanting to disrupt the relationship
- Wanting to reassert vitality or sexual ability in the face of illness or mortality
Repercussions
- Emotional: frustration, embarrassment, anger, shame, fear, anxiety, depression
- Physical: headaches, insomnia, weight change
- Workplace: impaired decision making, reduced productivity, increased absenteeism, job dissatisfaction
It can create a conflict between a clinician’s right to a safe work environment and their duty to do the best for the patient.
Common responses
- Passive: ignore it, joke about it, “it is my fault”, reluctant to address it. Behaviours have the potential to escalate.
- Aggressive: belittle and punish the patient, tolerate no sign of impropriety. Makes it difficult to act as healer.
- Assertive: knows when to ignore or address at a low level and when to react more strongly. Creates a better balance between healer and safety.
The assertive response, with the escalation pitched correctly, is the goal.
Reacting in the moment
Immediate thoughts you might have when a patient says something inappropriate: did I hear it correctly, did they really say that? Could it have meant something else? Are there cultural differences that might lead to misunderstandings? Is there some other factor that might be relevant? Then: what if it continues?
Escalation strategies
For verbal behaviour, a three-tier escalation:
- Yellow (where doubt might exist): play it light but highly professional.
- Orange (if it continues): say something immediately; have something practised and ready to go.
- Red (if it continues or escalates): stop treatment and tell them why you have stopped; leave the treatment space; inform your clinical supervisor as soon as possible.
For physical behaviour, there is no yellow tier: go straight to the orange or red response, with the same content as above.
Keeping yourself and others safe
- Treat in a more public space
- Have other staff present
- Use treatment methods with less physical contact
- Keep an emotional distance
- Inform your clinical supervisor
- Report a professional concern on Moodle
Important
Do not think it is part of the job. You have a right to keep yourself safe.
The lecture also poses, without answering it, whether a patient with an acquired brain injury should be treated any differently. [slide does not elaborate]
Reporting a professional concern
The reporting system is confidential and secure. The system does not allow the committee to look up the student who reported a concern. You can put your name to a report if you wish the committee to feed back to you.
Where to find it: Moodle course page, via the Overview tab and then the Support button, which leads to the Otago Medical School Support page. That page covers reporting concerns (professional, or hazard/incident), student associations, Otago Medical School support including the student care co-ordinator, and University of Otago support services.
What counts as poor professional behaviour in a learning environment: intimidating teaching practices; cultural or racial discrimination; gender or sexual orientation bias; lack of inclusiveness or respect; unprofessional behaviour including rudeness, offensiveness or threats; loud or abusive language; lack of cordiality. The Event Reporter form adds sexualised behaviour towards students to this list.
A separate pathway exists for health and safety issues: injury, illness, incident (something that could have caused harm to a person or damaged property/environment), and near miss (something with the potential to cause injury or incident), reported via a “Report a hazard or incident” button.
Behavioural Assessment Committee
Strapline: “Helping staff and students behave better towards each other.” The Committee reviews reports from students about intimidating or unprofessional behaviour in the teaching environment, and aims to resolve concerns through informal conversations. Its Moodle book covers the Committee, its processes, and how to make a report, with FAQ tabs on the Red Button and reporting, the Committee, policies and standards, support and advice, and urgent situations. FAQs cover what happens when you click the Report a Concern (Red Button), why you would use it, whether you have to give your name, whether the report stays confidential, whether reporting affects your grades, what to do if you are unsure whether an event needs reporting, and how to withdraw a report.
For urgent help, if immediate safety or wellbeing is at risk, call Emergency 111 (Police/Ambulance) or contact your local Mental Health Crisis Team.
Committee membership as listed: Acting Chair Suzanne Pitama; Faculty of Medicine Dunedin Year 2/3 rep Ruth Barnett; Dunedin Year 4/5/6 rep John Woodfield; Christchurch rep Rose Crossin; Wellington rep Jonathan Kennedy.
Confidentiality assurance on the Event Reporter form: your information is not linked in any way to information about your own progress at the Faculty of Medicine, so you can report freely without worrying about impact on your progress. Reports are used to ensure you are supported, to follow up where needed, and to change the environment to reduce the likelihood of similar events. Forms are collated by the Secretary and distributed to the Behavioural Assessment Committee, which determines appropriate action and responds to you.
Event Reporter form fields:
- When did the event happen (date)
- Name(s) of the person(s) the report is about (optional)
- Where you were when it happened (e.g. in a tutorial, a clinical setting, a study space), as descriptively as possible
- Who else was present
- What happened, in as much detail as you are comfortable providing
- Your name, to allow follow-up (optional)
- Someone else to follow up with, such as a group rep, if you would prefer
- Where you are based (dropdown)
- Your email address, to allow follow-up (optional)
Gifts
Worked scenario: you have successfully treated Joe, a thirteen-year-old with severe asthma, and supported him and his family throughout treatment. At the end of treatment Joe’s mother gives you a batch of homemade biscuits. Do you accept? What if instead she gifted an old family watch? What makes a gift appropriate or inappropriate?
What makes a gift appropriate or inappropriate
- Monetary value
- Timing: during treatment or at the end of treatment
- Obligations set up in the recipient: is the gift given for that purpose? Does it create unrecognised feelings in the recipient, making them feel special? Does it mean the recipient provides better care or better access for the gift-giver?
MCNZ guidance on gifts
- Do not seek or accept any inducement, gift or hospitality that may affect, or be perceived to have the capacity to affect, the way you prescribe for, treat or refer patients.
- Patients and/or their whānau may wish to present small or consumable gifts or koha as a gesture of appreciation. These will generally be acceptable provided they are token in nature and do not include cash donations.
- Any gift must be openly declared to ensure transparency: documented in the patient’s records and reported to your employer or manager.
- Never give gifts to a patient: the patient may feel obligated to reciprocate, or interpret the gift as an indicator of a personal relationship.
- There may be situations where refusing a gift or koha is difficult, impolite, or appears culturally insensitive.
- You can seek advice from a trusted colleague, your medical indemnity insurer, or your professional college or association.
MCNZ on professional boundaries in the doctor-patient relationship (updated 2018)
- Doctors are responsible for maintaining appropriate professional boundaries in the doctor-patient relationship.
- It is usually considered unethical to accept gifts, monetary or otherwise, from your patient.
- Financial dealings with patients other than fees for care provided are generally unacceptable.
- In most instances it is unwise to hold an Enduring Power of Attorney for your patient.
- All communication with patients, including via social media and other electronic communications, must be appropriate and professional.
Treating yourself and those close to you
Worked scenario: Hannah, a doctor, is approached by her sister Kate for a prescription for the contraceptive pill. Hannah knows Kate does not have much money. Should Hannah provide the prescription? Would you be happy to treat family members? What are the advantages and disadvantages? What cultural expectations might be in play?
Advantages:
- Rapport could be established quickly because Hannah presumably knows Kate well
- Hannah would know Kate’s family and medical history (though this assumption may not be correct)
- Possibly a cheaper service (though whether that is appropriate is itself a question)
- Easier access for Kate
Disadvantages:
- Difficult to establish and maintain a professional relationship and boundaries (e.g. Kate may feel she can call any time)
- Hannah may think she knows Kate’s medical history and make assumptions
- Kate may not be willing to tell Hannah all the clinically relevant information
- Health information must be kept confidential, which could be difficult in family circumstances
- It might be difficult for Kate to choose an alternate provider if she was unhappy
- Complicated if treatment is ineffective, has side effects, or Hannah makes an error
- Lack of objectivity may change how Hannah treats Kate as a patient
- Payment can be an issue
- Family dynamics can become complicated
- Due diligence may not be maintained, e.g. poor record keeping
MCNZ: avoid treating yourself or those close to you
- Wherever possible you should not treat yourself or those close to you. Providing treatment in the context of a close personal relationship can adversely affect the standard of care you provide. This is also true when you self-diagnose or prescribe for yourself.
- Council expects you to have your own GP to provide ongoing care and objective treatment of any health conditions. Your GP is also best placed to ensure your clinical records reflect your long-term health needs and management.
- Those close to you may change over time. Be alert to changes in relationships, such as a friendship or emotional connection developing. This applies to any relationship, including with patients, family/whānau members, friends and colleagues.
Key points from the fuller MCNZ statement:
- Wherever possible do not treat yourself or those close to you: clinical objectivity may be compromised, and patient outcomes and continuity of care may be adversely affected.
- If circumstances exist where there is no practical alternative, you must provide best practice care consistent with what you would provide to any other patient with the same condition in similar circumstances.
- Where treatment is provided, you must inform the patient’s usual GP or healthcare provider, with the patient’s consent.
- Situations where you must not treat yourself or those close to you:
- issuing medical certificates, death certificates, and conducting medical assessments for third parties
- providing psychotherapy
- providing recurring treatment or ongoing management of an illness or condition
- performing complex procedures
- performing sensitive examinations
- prescribing medication with a risk of addiction or misuse, controlled drugs, and psychotropic medication (the only exception is in an emergency)
Sexual boundaries
Worked HDC case: Natalie has been a patient of Dr Smith, a GP, for 15 years. She has attended over several months for a poorly healing lesion. Dr Smith has been kind to her, spending time chatting about cafes and magazines and sharing ideas. Natalie has told him she was having marriage difficulties. Before Christmas she came to the clinic for an after-hours appointment and gave him a bottle of gin, reciprocating a bottle of port he had given her earlier. They had a drink and Dr Smith kissed Natalie. The lecture asks for your gut reaction, what warning signs could have alerted the doctor that boundaries were about to be breached, what could have been going on in the doctor’s life that made him more likely to breach boundaries, and what the Medical Council says about sexual relationships with patients.
The rules
- It is never appropriate for a doctor to engage in a sexual relationship with a current patient.
- It is also inappropriate to enter into a relationship with a former patient or a close relative of a patient if this breaches the trust the patient placed in the doctor.
- It is never acceptable if:
- the doctor-patient relationship involved psychotherapy and/or long-term emotional support or counselling
- the patient has or had a condition or impairment likely to confuse their judgement
- the patient has previously been sexually abused
- the doctor-patient relationship is ended in order to initiate a sexual relationship
Why
- A breach of sexual boundaries may cause emotional and/or physical harm to both the patient and the doctor.
- Trust in the doctor-patient relationship is the basis of the professional relationship.
- The doctor-patient relationship is not equal. Doctors can influence and possibly manipulate some patients, so even if a patient has consented to a sexual relationship it is still considered a breach of sexual boundaries.
- Sexual involvement with a patient impairs clinical judgement.
- Only the highest standard is acceptable, and the professional doctor-patient relationship must be one of absolute confidence and trust.
Former patients and the persisting power imbalance
A sexual relationship with a former patient will always be regarded as unethical if it can be shown that you have used any power imbalance, knowledge or influence obtained while you were the patient’s doctor. You must recognise the influence you have had as the patient’s doctor, and that the resulting power imbalance may continue for some time after the patient stops consulting you.
Where responsibility sits
- As the professional, it is your responsibility to maintain sexual boundaries with your patients.
- The onus is always on you to behave professionally, and to ensure every interaction with a patient is conducted in an appropriate professional manner.
- The community and the profession expect you to have integrity. The community must be confident that you will maintain professional boundaries and that no patient will be at risk.
- It is not acceptable to blame a patient for any of your transgressions.
Sexual boundaries in psychiatry (Gabbard, 1999)
- The clinician is equated with a parent in the transference, so the relationship is symbolically incestuous.
- It is a frank exploitation, in the sense that the clinician’s needs are placed ahead of the patient’s needs.
- It is an abuse of power, because the professional is being paid to help the patient with psychological difficulties.
- It is a failure to provide the service for which the patient has contracted the clinician.
How boundary violations happen
- Boundary violations are erroneously viewed as being committed by a few “bad apples”.
- The slippery slope: a series of non-sexual boundary crossings that lead to boundary violations and sexual relationships.
- Public perception, and belief within the profession, is that female doctors are safer.
HDC case decisions are searchable: a search for “boundaries” filtered to general practitioners returned 27 results, including “Breach of sexual boundaries with current patient” (Rights 2, 4(2), June 2013), “Personal relationship with patient” (Rights 4(2), August 2020), and “Sexual exploitation by general practitioner” (Rights 4(1), 4(2), March 2013).
Professional support
Protective measures for the clinician:
- Have your own GP
- Peer support
- Keep yourself connected socially and professionally
- Professional mentoring
- If in doubt, ask: whose needs are being met by my action?
- Litmus test: would I be embarrassed to tell someone about this?
Self-test
- Define professional boundaries and state what they imply about the doctor-patient relationship.
- List the reasons professional boundaries are necessary.
- Describe the three zones of the continuum of professional behaviour, in order, and say which is the desired zone.
- Define inappropriate patient sexual behaviour and list five behaviours it includes.
- List the four risk factors for experiencing IPSB.
- Distinguish unintentional from intentional causes of IPSB, giving two examples of each.
- Distinguish the passive, aggressive and assertive responses to IPSB, and explain why the assertive response is preferred.
- Describe the yellow, orange and red responses to verbal inappropriate behaviour, and explain how the approach differs for physical inappropriate behaviour.
- List the measures for keeping yourself and others safe when a patient’s behaviour is a concern.
- Explain what confidentiality protections the professional concern reporting system offers a student who reports.
- List four examples of poor professional behaviour in a learning environment that warrant a report.
- What is the stated aim of the Behavioural Assessment Committee, and how does it try to resolve concerns?
- List the three factors that determine whether a gift is appropriate or inappropriate.
- Under MCNZ guidance, what kinds of gift from a patient are generally acceptable, and what must you do with any gift you accept?
- Explain why the MCNZ says a doctor should never give a gift to a patient.
- A student says accepting an antique family watch from a grateful patient’s mother is fine because she offered it freely. Using the transcript’s criteria, explain what is wrong with this reasoning.
- List four disadvantages of treating a family member.
- List the situations in which you must not treat yourself or those close to you, even if no practical alternative exists elsewhere.
- If there is no practical alternative but to treat someone close to you, what two obligations apply?
- State the MCNZ position on sexual relationships with current patients, and list the four circumstances in which a relationship with a former patient is never acceptable.
- Explain why a patient’s consent does not make a sexual relationship with their doctor acceptable.
- Explain the slippery slope concept of boundary violations, and what it implies about how violations should be prevented.
- Describe the four reasons Gabbard gives for why sexual boundary breaches in psychiatry are particularly harmful.
- List the professional supports that help a clinician maintain boundaries, and give the two self-check questions offered.
- In the HDC case of Dr Smith and Natalie, identify the non-sexual boundary crossings that preceded the breach, and link them to the continuum of professional behaviour and the slippery slope concept.
Answers
Reveal answers
- The parameters that describe the limits of a fiduciary (trust) relationship. They imply distance, respect and safety, and take the form of rules and guidelines about interactions with patients.
- Protection of both doctor and patient; safety and predictability; respect; autonomy; privacy; to facilitate and protect the patient-doctor relationship; to maintain objectivity and clinical competence.
- Disinterested/neglectful (under involvement), therapeutic relationship (the zone of helpfulness), and boundary violations (over involvement). The therapeutic relationship in the middle is the desired zone.
- “Any verbal or physical act of an explicit or perceived sexual nature, which is unacceptable within the social context in which it is carried out.” Includes staring, gestures, romantic gifts, suggestive remarks, propositions, genital exposure, unnecessary touching or physical proximity, threats and sexual assaults.
- Fewer years of clinical experience; working with those who have cognitive impairment; being a female student or staff member; treating male patients.
- Unintentional causes include the influence of drugs or illness affecting behaviour or judgment (e.g. CVA, TBI, delirium, psychosis), lack of insight or impulsivity, and not being aware of the professional boundaries that exist. Intentional causes include attempting to be intimidating to regain power, wanting to disrupt the relationship, and wanting to reassert vitality or sexual ability in the face of illness or mortality.
- Passive: ignore it, joke about it, blame yourself, reluctant to address it, with potential for behaviours to escalate. Aggressive: belittle and punish the patient, tolerate no impropriety, which makes it difficult to act as healer. Assertive: know when to ignore or address at a low level and when to react more strongly. Assertive is preferred because it creates a better balance between the healer role and safety.
- Yellow, where doubt might exist: play it light but highly professional. Orange, if it continues: say something immediately, having something practised and ready to go. Red, if it continues or escalates: stop treatment and tell the patient why, leave the treatment space, and inform your clinical supervisor as soon as possible. For physical behaviour there is no yellow tier; go straight to the orange or red response.
- Treat in a more public space; have other staff present; use treatment methods with less physical contact; keep an emotional distance; inform your clinical supervisor; report a professional concern on Moodle. Do not think it is part of the job; you have a right to keep yourself safe.
- It is a confidential and secure system. The system does not allow the committee to look up the student who reported. You may add your name if you want feedback. Information on the Event Reporter form is not linked to any information about your progress at the Faculty of Medicine, so reporting will not affect your progress.
- Any four of: intimidating teaching practices; cultural or racial discrimination; gender or sexual orientation bias; lack of inclusiveness or respect; unprofessional behaviour including rudeness, offensiveness or threats; loud or abusive language; lack of cordiality; sexualised behaviour towards students.
- It reviews reports from students about intimidating or unprofessional behaviour in the teaching environment, with the aim of resolving concerns through informal conversations. Its strapline is “Helping staff and students behave better towards each other.”
- Monetary value; timing (during versus at the end of treatment); and the obligations the gift sets up in the recipient, including whether it was given for that purpose, whether it creates unrecognised feelings and makes the recipient feel special, and whether it leads the recipient to provide better care or better access.
- Small or consumable gifts or koha from patients or whānau as a gesture of appreciation are generally acceptable, provided they are token in nature and do not include cash donations. Any gift must be openly declared for transparency, documented in the patient’s records and reported to your employer or manager.
- Because the patient may feel obligated to give something in return, or may interpret the gift as an indicator of a personal relationship.
- It fails the monetary-value test, since an antique family watch is not token or consumable and is not a small gift; MCNZ says it is usually unethical to accept gifts, monetary or otherwise, from a patient. It also risks setting up obligations in the recipient, creating unrecognised feelings, and affecting or appearing to affect the care or access provided. Free offering by the giver does not address any of these criteria.
- Any four of: difficulty establishing and maintaining a professional relationship and boundaries; assuming you know the person’s medical history; the patient not being willing to disclose all clinically relevant information; difficulty maintaining confidentiality in family circumstances; difficulty for the patient in choosing an alternate provider if unhappy; complications if treatment is ineffective, causes side effects or involves an error; lack of objectivity changing how you treat them; payment problems; complicated family dynamics; due diligence such as record keeping not being maintained.
- Issuing medical certificates, death certificates and conducting medical assessments for third parties; providing psychotherapy; providing recurring treatment or ongoing management of an illness or condition; performing complex procedures; performing sensitive examinations; and prescribing medication with a risk of addiction or misuse, controlled drugs and psychotropic medication, the only exception being an emergency.
- You must provide best practice care consistent with what you would provide to any other patient with the same condition in similar circumstances, and you must inform the patient’s usual GP or healthcare provider, with the patient’s consent.
- It is never appropriate for a doctor to engage in a sexual relationship with a current patient. With a former patient it is never acceptable if the relationship involved psychotherapy and/or long-term emotional support or counselling; if the patient has or had a condition or impairment likely to confuse their judgement; if the patient has previously been sexually abused; or if the doctor-patient relationship was ended in order to initiate a sexual relationship.
- Because the doctor-patient relationship is not equal. Doctors can influence and possibly manipulate some patients, so even a consented relationship is still considered a breach of sexual boundaries.
- The slippery slope is a series of non-sexual boundary crossings that lead to boundary violations and sexual relationships. It implies that violations are not confined to a few “bad apples” but arise progressively, so prevention means recognising and stopping the early non-sexual crossings.
- The clinician is equated with a parent in the transference, making the relationship symbolically incestuous; it is a frank exploitation because the clinician’s needs are placed ahead of the patient’s; it is an abuse of power because the professional is paid to help the patient with psychological difficulties; and it is a failure to provide the service for which the patient contracted the clinician.
- Have your own GP; peer support; keeping yourself connected socially and professionally; professional mentoring. The self-checks are “whose needs are being met by my action?” and the litmus test “would I be embarrassed to tell someone about this?”
- The crossings were: prolonged personal chat about cafes and magazines and sharing ideas rather than clinical matters; receiving the patient’s disclosure of marriage difficulties, which is a form of emotional support; the doctor giving the patient a gift of a bottle of port, which MCNZ says you should never do since it may be interpreted as an indicator of a personal relationship; accepting a reciprocated gift of gin; an after-hours appointment; and drinking alcohol together. On the continuum, the relationship had drifted from the therapeutic zone into over involvement, and the sequence of non-sexual crossings culminating in the kiss is exactly the slippery slope. Regardless of the patient’s participation, the onus was on the doctor as the professional, and blaming the patient would not be acceptable.