UNITING PHYSICIANS & PATIENTS AS A VOICE IN HEALTH CARE
When a patient, the patient's advocate, or another professional contacts the medical board alleging that a physician has exhibited inappropriate sexual behavior, talk, or innuendo, there is an assumption that the complaint has merit. Moreover, if the doctor has already been the subject of past complaints to and/or investigations by the BMP for any reason, the BMP will review the previous cases as well as the new complaint.
The professional literature reports that sexual abuse claims more often than not have a basis. But there are situations in which physicians may be falsely accused of substantial sexual boundary violations with patients. These may involve misinterpretation of remarks made in haste. Also, patients may be angry with or frightened by the doctor for reasons that are not immediately apparent. Frequently, such cases are associated with unpaid bills, a perception that the doctor is not sensitive to the patient's concerns, and in some cases, the false belief that the doctor is in love with or desires to establish an intimate relationship with the patient.(7) For that reason, staff from the BMP and the attorney general's office are trained to consider such situations and to not rush to judgment about the facts or presume that the doctor is guilty when they investigate a complaint.
In 5 states, sexual misconduct by professionals is now addressed under civil statute, and in 16 states, including Minnesota, sexual misconduct by health professionals is considered a criminal offense as well.(5)
There is no single diagnostic profile or set of psychiatric criteria to describe physicians who become involved in sexual relationships with their patients. In many cases, physicians—and sometimes patients who cross sexual boundaries—are using/abusing alcohol, illicit drugs, or prescription medications; have untreated mental disorders; or have a combination of these problems. The Minnesota Health Professional Services Program (HPSP) (www.hpsp.state.mn.us) provides monitoring for physicians who are seeking treatment for chemical dependency or mental health issues.(8) The HPSP monitors physicians and other licensees who have such diagnoses and are engaged in therapy or rehabilitation. Their treating physicians and other professionals submit periodic reports to HPSP, which report on a physician's progress or compliance to the BMP.
A small number of sociopathic doctors sexually exploit patients simply because they believe they can get away with this behavior. These doctors are unlikely to pursue meaningful psychotherapy; and they may or may not tolerate being monitored by the BMP. Most offending physicians, however, realize that they have made poor choices and regret them. Carr contrasts the characteristics of physicians who can achieve rehabilitation with those who cannot. Among the disease and physician characteristics that Carr considers to be indicators of a positive prognosis for physicians who have committed sexual boundary violations are: having a substance-related disorder diagnosis, being able to be honest, being motivated/compliant, showing remorse, showing empathy for the victim (in this case, the former patient), insightfulness, having a recovery and peer support system in place, having an ongoing positive relationships with family and significant others, having recent identifiable psycho-social stressors, and having treatable mental disorders.(6) Bad prognosticators include: acting out despite sanctions or when under monitoring, refusing to end a sexual relationship, being profoundly self absorbed (narcissistic), being very dependent on the approval of others, refusing to allow or accept advice and support from peers and family, having pervasive boundary violations, and showing strong antisocial traits.
For most physicians, the ultimate goal of their treatment is rehabilitation and return to medical practice. To achieve this, they must be able to sustain safe and healthy doctor-patient relationships. Based on our experiences working with impaired physicians, we agree with Carr that most physicians who have committed a sexual boundary violation can be rehabilitated so that they can return to practice.(6) This may require different practice settings or degree of supervision. In some cases, career change may be necessary. For physicians in psychotherapy, treatment goals and strategies include an understanding of factors leading to doctor-patient boundary violations and rehearsing scenarios for alternative behaviors. Thus, part of the psychotherapy is an ongoing analysis of the physician's skill and comfort maintaining appropriate professional boundaries with patients.
Nonetheless, the priority of the medical board is to protect the public from exploitative doctors. For that reason, the psychiatrist, counselor, or therapist working with a physician who has crossed boundaries should not offer guarantees of confidentiality if the problem behavior reoccurs. In this sense, the therapy model for treating these physicians is similar to that of military psychiatrists or occupational physicians who examine patients for work readiness and report to the employer if the subject is unfit for duty. This obligation can pose a conflict for the psychiatrist or therapist unless the treating doctor and the patient are each committed to the primary goal of public protection.
Physicians who cross sexual boundaries with patients place themselves in great peril. They risk tainting or destroying their professional reputations; damaging their health; and losing their jobs, contracts with payers, and hospital privileges. They jeopardize their financial security, bring shame to and conflict within their families, and may lose their license to practice medicine. Public awareness about the problem of sexual boundary violations by professionals is growing, as is disdain for all persons in fiduciary roles who engage in sex with those for whom they are responsible and over which they have power, whether they be wards, patients, or parishioners. The clergy scandals in the Catholic church highlight this growing public intolerance. Sexual misconduct is a serious black mark on a physician's career. However, some physicians who demonstrate remorse, undergo therapy, and are willing to work with the Board of Medical Practice to regain the public trust can reclaim their careers.
The opinions expressed in this article are the author's and do not represent positions of the Board Medical Practice or any other state agency.