UNITING PHYSICIANS & PATIENTS AS A VOICE IN HEALTH CARE
Health services professions agree that sexual relations between treating clinicians and their patients are harmful and should not be tolerated. Minnesota law and regulations encourage identification of offending clinicians in order to protect the public. Regulatory agencies such as the Minnesota Board of Medical Practice seek to stop licensed professionals from engaging in sexual behavior with patients and also, when feasible, to restore medical professionals to competent practice. The authors recommend individualized psychiatric assessment and therapy for physicians who violate professional standards.
The term "professional sexual misconduct," often used to refer to physicians' sexual boundary violations with patients, is somewhat of a misnomer because there is simply no professional justification for doctors or other clinicians to engage in sexual behavior with their patients. Sex between physicians and patients, including flirting and seductive talk, clearly undermines patient trust, violates the fiduciary responsibilities of physicians to patients, isolates physicians from their medical colleagues, and cripples the therapeutic power of the doctor-patient alliance. So the zero-tolerance standard for sexual misconduct is appropriate and in no way puritanical or prudish. The standard is based on a broad consensus that the medical profession, policymakers, and the professional licensing boards must be empowered to protect the public. Despite agreement about these standards, physician-patient sexual relationships continue to occur. Although their prevalence is not fully known, published surveys have indicated that 9% of doctors acknowledge having had sexual contact with patients in the past, and 23% of patients report past sexual contact with physicians.(1)
It is not believed that doctor-patient sex is on the rise in Minnesota, despite a lack of periodic, confidential surveys of Minnesota physicians about sexual involvement with their patients. Nonetheless, heightened public and professional awareness here and nationwide is leading to better identification of suspected cases.
Doctors who serve as reviewers and consultants for the Minnesota Board of Medical Practice (BMP), which investigates such reports, note the slippery slope of how boundary crossings progress to boundary violations. Both physician and patient, knowingly or unknowingly, may allow a relationship to progress toward one that is inappropriate.(2) A "grooming sequence" ensues when patient and physician begin addressing each other by first name. The professional persona of the examining room fades at the door, physician self-disclosure turns into doctor revelations of personal and sexual feelings, office visits may be extended while the length of other patients' visits is disregarded, and physician record keeping deteriorates for the patient with which the physician is involved. Physical contact begins with hugs and kisses on the cheek; the physician may discuss other patients with the special patient; they begin meeting at a restaurant outside the office; the physician stops charging the patient, and/or the patient's bill mounts without discussion of it or attempts to collect on it; office visits for the special patient are moved to the end of the day; and dating begins.
It is not uncommon for the patient to wish to continue the "new" relationship. The patient at times will threaten to turn the doctor in to the medical board or notify his or her clinic authority if the doctor threatens to end the relationship, and very often the doctor becomes anxious about maintaining the secret. Most complaints to the BMP occur after it becomes clear to the patient that the doctor is unwilling or unable to sustain or terminate the relationship.
Such complaints are relatively rare. The Minnesota BMP, which regulates the state's 18,000 physicians, reported that 20 (2%) of its 941 total complaints about physicians and other health care providers it oversees in fiscal year 2004 alleged that a licensee had engaged in sexual activity with a patient.(3) Complaints of sexual misconduct are automatically referred to and investigated by the Minnesota Attorney General’s office. Investigation into the complaint often involves the patient, doctor, doctor's staff, and other parties. A doctor's medical record also is carefully scrutinized.
Most physicians encourage patients to inform them or their associates when grievances or questions arise about their care. However, approaching a doctor about sexual issues, especially when it involves the doctor's own behavior, or when a patient-doctor relationship has already become sexual is not often a realistic option for patients or their families. Patients already feel exploited by the doctor, and they commonly believe that the doctor's colleagues will not be receptive to their concerns. Patients who have discussed their experiences with representatives from the BMP or investigators from the attorney general's office or during psychotherapy often report that they expect to be humiliated, put off, or bullied by the doctor because so much is at stake for the doctor.
Indeed, the doctor is responsible for the conduct of a doctor-patient relationship when sex occurs.(4) Thus, patients who perceive or experience unwelcome or invited sexual behavior from their doctor cannot in most cases work this out with the doctor. Moreover, when the patient does notify the doctor's clinic or employer who determines that the patient's complaint is credible, the doctor is often suspended from clinical practice and may be terminated as an employee.(5) Patients in such cases need special attention from the clinic to cope with their trauma and needs for care continuity. Doctors should immediately seek legal counsel and consult their professional liability insurance carrier, which may or may not indemnify sexual violations with patients.
To address the inherent imbalance of power in the doctor-patient relationship, Minnesota passed legislation in 1996 not only prohibiting physician conduct that is sexual or that may be reasonably interpreted by the patient as sexual and verbal behavior that is seductive or sexually demeaning to a patient, but also identifying the grounds by which a physician may lose his or her license to practice medicine.(6)