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Respecting boundaries


Staying on side

The "slippery slope" (Page 1 of 2)


Male roofer working on roofBoundary crossings do not usually cause harm to the patient. However, repeated crossings or progressively bolder minor violations may become a "slippery slope" resulting in a more serious boundary violation.

A slippery slope can play out in many different ways. Consider the following cases and identify where the physician or medical trainee is on the slippery slope.

Intimate procedures or examinations

Case: Inappropriate conduct during an examination
Woman with her head in her hands

Background

A family physician is asked to see and examine a young woman as an urgent appointment for counseling regarding an unwanted pregnancy.

As he is rushed, the physician does not leave the room while the woman is undressing. The office has run out of drapes so he gives the patient a small hand towel to cover her lower abdomen.

The physician proceeds to do an internal examination without explaining to the patient what he is doing. He does not have a chaperone and when exiting the room leaves the examination room door open while the patient redresses.

Outcome

The woman complained to the College, stating she felt traumatized and sexually abused by the experience.

Think about it

  • List the poor decisions made by the physician.
  • How could the physician's behaviour impact the patient?
  • How would this impact the patient's future relationships with healthcare providers?

Lessons learned

It is not uncommon for physicians to face allegations that they have violated a boundary while performing intimate procedures or examinations (for example, gynecological examinations).
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To minimize misunderstandings during intimate procedures or examinations physicians should:

  • Adequately and clearly explain to patients a procedure or examination, and why it is being performed.
  • Obtain a patient's informed consent for a specific procedure or examination.
  • Give patients sufficient privacy to undress (and redress).
  • Avoid altering or removing a patient's clothing without express consent.
  • Offer to have a chaperone present during sensitive examinations or procedures.
  • Document any steps taken to minimize a patient's discomfort with an examination or procedure.

Dual relationships — Professional and social

Physicians may well have patients with whom they socialize or have friendships. In these cases, physicians should still be conscious of the potential for boundary crossings and, as much as possible, separate their personal and professional obligations. The closer the relationship is between the physician and the patient, the greater the risk of a perceived boundary violation.

Case: Investment advice gone awry
Stock exchange board with values

Background

A stockbroker follows up with his cardiologist concerning coronary arterial disease.

While indulging in small talk, the cardiologist asks what stocks are recommended. The broker replies, and after finishing his afternoon clinic the cardiologist purchases those stocks from a different broker.

On a later visit, the cardiologist tells the patient that he has lost money on those stocks. The broker feels badly, but also wonders how this would affect the quality of care he would receive.

Possible patient outcomes

  • The patient may no longer trust the doctor's medical advice, fearing the cardiologist may give inferior care, "to match the advice he got."
  • The patient may go elsewhere, with undesirable delays in treatment.

Think about it

  • Can you think of any other outcomes that could harm the patient, physician, or both?
  • What are some questions you can ask yourself to assess whether boundaries are being blurred in the doctor-patient relationship?

Suggestions

Questions you can ask yourself to assess whether boundaries are being blurred include:  
  • Do I seek advice for personal benefit during a clinical encounter?
  • How will the patient view this?
  • How would a neutral observer view this arrangement?
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Case: Business relationships with patients
For sale sign in field

Background

During a routine office visit a family physician becomes aware that an elderly patient has land for sale. He has cared for the patient for many years and they often discuss business.

The physician enters into a sales agreement with the patient to buy the land. The physician's lawyer drafts a purchase agreement after having the land surveyed for water and sewage requirements.

Before the sale is finalized the patient changes his mind.

The physician starts a legal action to recover his legal and survey costs. Because of the legal action, the physician terminates the doctor-patient relationship, prompting the patient to complain to the medical regulatory authority (College).
Regulatory authority, professional:  Licensing body for a profession.
Provincial/territorial medical regulatory authority (College)
Body that regulates the practice of medicine in each province or territory to ensure the public receives quality medical care from physicians. The responsibilities include:
- Issuance of certificates of registration to allow the practice of medicine,
- Maintenance of standards of practice,
- Investigation of complaints against physicians, and
- Remedial education or discipline for those guilty of professional misconduct or incompetence.
The medical profession is self-regulating in Canada. Each authority has an investigative process and committee structure to make decisions on different issues and complaints.

Lessons learned

  • The College concluded the physician's conduct was unprofessional.
  • The physician subsequently abandoned the legal action and wrote a letter of apology to the patient.
  • The College accepted the physician's letter of apology and his commitment not to enter into personal transactions with patients.
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Case: Should I hire my patient?
Close up of bucket with female standing behind it

Background

A young female physician is starting her practice after finishing residency and having her first child.  She is challenged by the demands of work and managing her home and family.

During a routine clinic visit a patient tells her that she is a house cleaner and looking for work. The young doctor is thankful for the fortunate timing and hires her patient. The patient is grateful for the income.

Think about it

  • Is it appropriate to hire a patient?
  • In what ways can this influence the doctor-patient relationship?
  • Can you identify potential medical-legal risks with this case?
  • How might hiring your patient lead to a College complaint or legal action against you?

Lessons learned

  • Physicians should avoid entering into business deals with patients.
  • At least one College has noted that these transactions can result in a finding of professional misconduct, and the finding can be based solely on the power imbalance between the physician and patient.
  • Patients may feel pressured to enter into a personal transaction with their physician out of fear that refusing might jeopardize their relationship with the physician or the quality of care they will receive.
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  • Be aware of when a therapeutic boundary is being crossed.
  • Bringing your personal life into the relationship with a patient carries the risk of impinging on the quality of medical care and has potentially serious consequences.

Physicians may be asked to act as a patient's power of attorney. In most cases, physicians should respectfully decline these requests, especially when another suitable individual is reasonably available to take on the role.

Self-disclosure

Case: I know what you mean
Female patient speaking with female physician

Background

A medical student sees a 16-year-old patient for persistent headaches. When the student asks the patient if she is experiencing a high level of stress in her life, the patient confides that her parents are going through an acrimonious divorce.

The medical student describes her own experiences with her difficult divorce, saying "It is really difficult for me; my spouse doesn't understand the rigors of medical training. Some days I don't know if it is all worth it."

Think about it

Discuss the appropriateness of the medical student's comment.
How might a comment like this make the patient feel?

Lessons learned

While it may be appropriate in some circumstances to share with your patients limited general information about yourself (for example, a favourite sports team, the fact that you have a pet), it is generally improper to disclose detailed personal information or share intimate details about your personal life (e.g. relationship problems).
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It is unacceptable for physicians to discuss their sex life or sexual relationships with patients. Not only can divulging intimate personal information make patients uncomfortable, it could lead the patient to misunderstand the nature of the relationship and see it as a friendship rather than purely professional.