Professional Boundaries in the Medical Practice

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The doctor-patient relationship is rooted in trust. Patients often present their most vulnerable selves to their physicians with the trust that they will remain respectful and professional at all times. An important part of establishing an atmosphere of trust is maintaining clear professional boundaries with patients. If this trust is compromised it can be damaging to the patient, your reputation, your practice, and the medical community.

Not all cases are clear when it comes to avoiding boundary violations. Sure, it is easy to recognize blatant violations such as having sexual relations with a patient, but what about attending a wedding or funeral? What if a patient “friend’s” you on Facebook? When does the doctor-patient relationship change to a friendship? Blurring this boundary can change the dynamic between the provider and the patient, which can lead to misunderstanding and/or conflict. If a provider develops a dual relationship or assumes a second role with a patient, becoming a doctor and a friend can compromise impartial judgment and impact how care is delivered.

One of the most important reasons to maintain professional boundaries is to avoid an allegation of sexual misconduct. The American Medical Association takes a firm position against sexual contact between physicians and patients. Some states, such as California, make it a criminal offense for a physician to have sexual relations with a current or former patient (California Business & Professions Code §729(b)). Allegations of sexual misconduct are more frequent in the specialties of psychiatry and primary care, and are brought predominantly against male providers.

Some sexual misconduct claims can arise when a patient misinterprets appropriate behavior during a routine, medically necessary examination. These situations often arise in the lack of professional boundaries.

Easy things doctors can do to avoid boundary violations include:
  • Allowing patients to disrobe and dress in private and offer cover gowns and appropriate drapes.
  • Ask questions about sexual history when the patient is fully clothed. Such questions should be asked during a pelvic exam or examination of the breasts or genitalia only if directly related to a physical finding.
  • Communicate clearly with the patient about the reasons for and methods of examination. Obtain the patient’s verbal consent prior to performing any sensitive exam.
  • Have a chaperone in the room whenever possible. Document that the chaperone was present, including the chaperone’s name and title. It is also advisable to offer the patient the opportunity to speak with you in private without a chaperone present – possibly after the exam is completed and the patient is dressed.
  • If you are not sure whether you are (or could be seen to be) abusing your professional position, you should seek advice about your situation from an impartial colleague, your defense counsel, or your medical association.
Recommendations for psychiatrists include:
  • Avoid contact with patients outside of the office.
  • Do not accept or give gifts.
  • Keep your private life separate from the therapeutic relationship.
  • Avoid excessive self-disclosure.
  • Remember you are modeling appropriate boundaries for patients.
  • Be aware of any intimate feelings that develop towards a patient.
  • (California only) If patients disclose a history of sexual and/or romantic experiences with a health care professional and you are a California psychiatrist, you must provide them with the “Professional Therapy Never Includes Sex” brochure.

Taking a few precautions to maintain professional boundaries can go a long way toward eliminating allegations of misconduct. If a patient does accuse you of and boundary violation or misconduct, contact the MIEC Claims Department for assistance.