General practice psychiatry

September 2013

Professional

Managing professional boundaries

Volume 42, No.9, September 2013 Pages 666-668

Sara Bird

The maintenance of boundaries in the doctor–patient relationship is central to good medical practice and the appropriate care of patients. This article examines the nature of boundaries in medical practice and outlines some strategies to minimise the risk of a boundary violation.

Case study

A general practitioner (GP) had been seeing his 32-year-old patient for a number of years. The patient’s two young children and her husband also attended the practice. Recently, the patient had disclosed to the GP that she was experiencing marital problems and she was feeling depressed. The GP provided the patient with counselling and also a referral to a psychologist. One of the patient’s main concerns was her financial situation if she left her husband. During one consultation, the patient told the GP that she had started a house-cleaning business because she could do the work when the children were at school and at other times that suited her. The GP agreed to let the patient clean his home.

Over the ensuing months, the patient started to clean the GP’s house at times when he was at home. A pattern developed where the GP and patient would share a cup of tea and later a meal together. Over time, a personal and sexual relationship developed. Some months after the sexual relationship commenced, the GP received a letter from the Australian Health Practitioner Regulation Agency enclosing a notification from the patient’s psychologist, which stated that the GP had engaged in sexual misconduct.

The case proceeded to a tribunal hearing, where a finding of unprofessional conduct was made against the GP.

Discussion

The underlying basis of any doctor–patient relationship is that the doctor commits to the relationship solely to serve the needs of the patient. In return, the doctor receives only remuneration and the personal satisfaction of undertaking meaningful and valuable work. Section 1.4 of Good medical practice: A code of conduct for doctors in Australia (the Code) states: ‘Doctors have a duty to make the care of patients their first concern and to practise medicine safely and effectively. They must be ethical and trustworthy.

‘Patients trust their doctors because they believe that, in addition to being competent, their doctor will not take advantage of them and will display qualities such as integrity, truthfulness, dependability and compassion.’1

Section 8.2 of the Code states:

‘Professional boundaries are integral to a good doctor–patient relationship. They promote good care for patients and protect both parties. Good medical practice involves:

  • Maintaining professional boundaries
  • Never using your professional position to establish or pursue a sexual, exploitative or other inappropriate relationship with anybody under your care. This includes those close to the patient, such as their carer, guardian or spouse or the parent of a child patient.’1

What is meant by the term ‘professional boundaries’?

Professional boundaries are parameters that describe the limits of a relationship in which one person entrusts their welfare to another and to whom a fee is paid for the provision of a service.2

Boundary issues include:

  • Boundary crossings, which are departures from usual professional practice that are not exploitative. On occasion, a boundary may be consciously crossed with the intention of actually assisting a patient’s management; for example, disclosing to a patient who has recently been diagnosed with cancer that one of your family members had also been diagnosed with the same type of cancer. However, at other times, boundary crossings may occur as part of a ‘slippery slope’ of moving from outside usual practice to inappropriate practice harmful to the patient.
  • Boundary violations are transgressions, which harm the patient in some way. Boundary violations are unethical and unprofessional because they exploit the doctor–patient relationship, undermine the trust that patients and the community have in their doctors, and can cause profound psychological harm to patients and compromise their ongoing medical care.

Good medical practice relies on trust between doctors and patients and their families. It is important to be aware that 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.

Sexual misconduct covers a range of inappropriate behaviours including:

  • Sexualised behaviour such as any words or actions that might reasonably be interpreted as being designed or intended to arouse or gratify sexual desire
  • Sexual exploitation or abuse, which includes sexual harassment (unwelcome behaviour of a sexual nature including, but not limited to, gestures and expressions), or entering into a consensual sexual relationship
  • Sexual assault, which ranges from physical touching (or examination without consent) to rape, is a criminal offence.3

The Medical Board of Australia will investigate a doctor who is alleged to have breached these guidelines and if the allegations are found to be substantiated, the Board will take disciplinary action against the doctor.

An analysis of doctors who were disciplined for professional misconduct in Australia and New Zealand between 2000–2009 revealed that the most common type of offence was sexual misconduct, which comprised 24% of the cases.4 The vast majority of cases (96%) involved male doctors. Two-thirds of these cases involved sexual relationships with patients, as opposed to other inappropriate sexual contact, such as unnecessary intimate examinations. The penalties for the cases were severe, with 81% leading to either deregistration or restrictions on the doctor’s clinical practice. While GPs had the highest overall number of cases resulting in disciplinary action, obstetricians and gynaecologists and psychiatrists had the highest rates of disciplinary tribunal action amongst medical practitioners.

Risk management strategies

Risk factors for boundary crossings and violations: the nature of medical practice

The practice of medicine has become less formal, with a more collaborative relationship with patients. GPs are more likely to use first names and develop an informal relationship with their patients. This can make it more difficult to maintain clear professional and personal boundaries, and may also be misinterpreted by patients.

By its very nature, medical practice involves an intimate relationship with patients. GPs often work closely with patients over many years and participate in their lives during stressful and traumatic periods. Highly personal and confidential matters are discussed and physical examinations, including intimate examinations, are performed.

Doctors’ risk factors

When doctors are under stress themselves, with insufficient emotional support, boundaries are more likely to be crossed and violated. Inexperienced doctors may also be naïve to the complex and problematic effects of boundary crossings.

Rarely, some doctors may be suffering from a mental illness, such as mania, which results in disinhibited behaviour. There are also a small number of predatory doctors with personality disorders who actively prey on patients.

Poor communication can also result in complaints that a doctor’s actions were inappropriate and/or sexually motivated. In these cases, the consultation and examination are appropriate and clinically indicated, but the doctor has not explained, and/or the patient has not understood why the doctor has asked a particular question or performed a particular examination.

Patients’ risk factors

The patients who are most vulnerable to boundary violations are women who have been sexually abused previously. Patients with dependent and borderline personality disorders are also at risk. These patients generally have considerable difficulty with all interpersonal relationships, and maintaining consistent and appropriate boundaries with these patients can be challenging.5

How can the risk of boundary violations be minimised?

The importance of maintaining a doctor’s own health and wellbeing cannot be overemphasised. Doctors who are personally or professionally isolated, under stress or unwell are more vulnerable to boundary violations.

If a doctor is having difficulty in managing boundary issues with a particular patient, discussion with a colleague and their medical defence organisation may be helpful.

The development of a sexual relationship between a doctor and their patient is often the culmination of a series of boundary crossings. An early awareness and warning of this process may help in managing the risk. A useful checklist to identify any risky behaviour with respect to boundaries is to ask yourself:

  • Is what I am doing part of accepted medical practice?
  • Does what I am doing fit into any of the recognised high-risk situations that I have learnt about?
  • Is what I am doing solely in the interest of the patient?
  • Is what I am doing self-serving?
  • Is what I am doing exploiting the patient for my benefit?
  • Is what I am doing gratuitous (not what the patient has asked for)?
  • Is what I am doing secretive or covert? Would I be happy to share it with my spouse, partner or colleagues?
  • Am I revealing too much about myself or my family?
  • Is what I am doing causing me stress, worry or guilt?
  • Has someone already commented on my behaviour, or suggested I stop?6

Competing interests: None.
Provenance and peer review: Commissioned; not peer reviewed.

Acknowledgement

This article has been provided by MDA National. This information is intended as a guide only and should not be taken as legal or clinical advice. We recommend you always contact your indemnity provider when advice in relation to your liability for matters covered under your insurance policy is required.
MDA National Insurance is a wholly owned subsidiary of the Medical Defence Association of Western Australia (Incorporated) ARBN 055 801 771 trading as MDA National incorporated in Western Australia. The liability of members is limited.

References

  1. The Medical Board of Australia. Good Medical Practice: A Code of Conduct for Doctors in Australia. Available at: www.medicalboard.gov.au/Codes-Guidelines-Policies.aspx [Accessed 23 July 2013].
  2. Gabbard GO, Nadelson C. Professional boundaries in the physician/patient relationship. JAMA 1995;273:1445–49.
  3. The Medical Board of Australia. Sexual Boundaries: Guidelines for doctors. Available at: www.medicalboard.gov.au/Codes-and-Guidelines.aspx [Accessed 23 July 2013].
  4. Elkin KJ, Spittal MJ, Elkin DJ, Studdert D. Doctors disciplined for professional misconduct in Australia and New Zealand, 2000–2009. Med J Aust 2011;194:452–56.
  5. Galletly CA. Crossing professional boundaries in medicine: the slippery slope to patient exploitation. Med J Aust 2004;181:380–83.
  6. Riley G. Managing Boundaries. Defence Update, MDA National. Autumn 2013.

Correspondence afp@racgp.org.au

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