It’s Not Just About Sex

It’s Not Just About Sex

November 2020

A broader definition of professional boundary violations in health care.

Pop quiz: Which of the following are professional boundary violations?

  • Chatting with patients on social media
  • Having a consensual romantic and/or sexual relationship with a patient
  • Writing a prescription for a colleague in the hallway

If you chose “Having a consensual romantic and/or sexual relationship with a patient” of course, you are correct. But if you did not choose all of the others, you may not have a full understanding of the many elements that professional boundaries encompass.

It’s not surprising that people associate boundary violations with sex. It’s what you hear about in the news for obvious reasons. Stories about practitioners hiring patients to paint their house or inappropriately sharing personal information don’t make for good headlines. They’re not, well, sexy enough.

But despite the media’s obsession, the vast majority of violations have nothing to do with sexual activity. That doesn’t make them any less harmful to patients — or less damaging to your career. Which is why PBI founder and CEO Stephen Schenthal, MD, wrote The Physician’s Guide to Professional Boundaries, a book full of applicable lessons for all clinicians.

“I can’t tell you how many times in the past 20 years, experienced practitioners taking our PBI Professional Boundaries Course have told me they don’t really need course because they’ve never really crossed any boundaries” Schenthal said. “They tell me they never had a sexual relationship with a patient, as if that’s all there is to say. They have no idea how much trouble they’re in.” The subtitle of Schenthal’s book — What you don’t know can end your career — explains the importance of truly understanding what professional boundaries are all about.

PBI Education  Professional Boundaries

The explanations practitioners mistakenly offer as proof of their innocence reveal some of the most common misperceptions.

“I never even touched them.”

As Schenthal said, many of those charged with sexual misconduct defend themselves by denying they ever had sex with a patient. But you don’t have to physically touch someone to violate the boundaries protecting them.

Professional boundaries are designed not just to protect patients from assault, which is a crime, but to make them feel safe in your care. Before they agree to remove their clothes and allow you to examine them, patients need to know they can trust you to do what is best for them, that you will always put their interests ahead of your own. Anything you do to undermine that trust is considered a boundary violation. If something you say or do- or fail to say or do- makes a patient feel uncomfortable, you have probably crossed a boundary. The moment they actually feel threatened, you have become a boundary violator.

It’s not up to you to decide if their concern is warranted. PBI’s Second Law of Professional Boundaries is “Perception is 9/10 of the law.” If a patient feels threatened when you compliment their attire or give them what you consider a reassuring hug, you have crossed a line. 

Where that line is depends on a variety of factors — your previous interactions with the patient, nuances of your behavior, and the patient’s personal history, to name just a few. As the professional in the room, it’s up to you to know where the line is for each patient in your care each time you see them so you can make sure they always feel safe and respected. (One of the key benefits of using a trained chaperone is that they can help you pick up on signs of discomfort you might otherwise miss, reassure anxious patients, and help resolve any misunderstandings or miscommunications right away.)

“I treated them the same as every other patient.”

Some boundaries are culturally determined. Conduct that is welcome in one culture may be seen as threatening in another. If you were raised in the U.S. and trained here, you probably would think nothing of examining an unaccompanied woman. But in other countries you might well be charged with sexual misconduct for examining her without a male relative in the room, even if she said nothing about this during the exam. If. on the other hand, you come from a culture where hugging is a normal part of patient-practitioner interaction, you are likely to find yourself facing charges in the U.S. for behavior you consider common courtesy, but others might consider intrusive or inappropriate.

The point is, both patients’ assumptions and your own have to be taken into account when considering professional boundaries. That’s not easy, given how unaware most people are about their own cultural assumptions. But as patient and provider populations grow increasingly diverse, sensitivity to cultural issues is becoming a crucial aspect of professional practice.   

“I was just helping a friend.”

It happens all the time: you dash off a prescription for a harried colleague or take a look at a kid’s injury as a favor for a worried neighbor. The problem with such seemingly benign interactions is that you are blurring the lines between your professional and personal roles. If your colleague came in for a scheduled appointment, there would be no ambiguity about your role. You would treat them professionally, taking a history and examining them before writing the prescription they requested—assuming you agreed with the need for that particular medication, and believed there was no reluctance on either of your parts about asking and answering questions during the history. If you were treating an injured child as a healthcare professional rather than as a friend, you would be sure to review their medical history, update their medical records and ensure appropriate follow-up. 

Dual relationships like these also compromise your objectivity. The stronger the non-professional relationship is, the more likely it is to influence your professional judgment. You may dismiss a close friend’s health concerns based on your personal history with them rather than your considered medical opinion or conversely, order more tests than are clinically warranted to soothe your personal anxiety about their welfare. Dual relationships can also compromise your patient’s trust in you. A patient who cares about you personally may be likely to hold back important information they think will worry or hurt you.

“I would never hurt a patient. I’m a caring person. That’s why I went into medicine in the first place.”

You lend a needy patient money for a prescription or agree to see a busy single parent after regular office hours. Such acts of apparent altruism blur the lines between personal and professional care by establishing a dual relationship where none previously existed. The patient you loaned money to may now feel too embarrassed to come in for an important follow-up appointment. The single parent may assume their after-hours visit implies more than professional involvement and end up hurt and angry when they find out otherwise. 

This doesn’t mean that being professional precludes thoughtfulness. There are ways to be caring without crossing boundaries. You might, for instance, refer patients in financial need to agencies that can help them pay for prescriptions, or officially schedule late office hours with your staff present on a regular basis to accommodate all patients with busy schedules. Whatever the solution, the goal is to avoid establishing or even suggesting a different relationship with one patient than you have with all others.

“It was consensual.”

There is no such thing as consensual sex with a patient. That’s not up for discussion. According to a 2013 article in the New York Law Journal, “Studies have proven that the physician’s tremendous power over the patient, coupled with the patient’s emotional and/or psychological vulnerability, deprives the patient of the ability to give true or valid consent to a sexual relationship with their physician.” The article goes on to cite a 1991 AMA report, which notes, “‘The lack of reliable or true consent on the part of the patient…has led researchers to compare physician-patient sexual contact with other sexually exploitative situations such as sexual assault and incest.’” These same concepts about power, consent, and exploitation apply to all clinicians, not just to physicians.

“I was just trying to establish rapport. I was taught to display empathy.”

Clinicians understand the importance of establishing good rapport with their patients. They believe that if they share similar experiences, they will create an understanding atmosphere. Or when a patient shares their troubles—whether they are going through a divorce, grappling with a difficult diagnosis, or raising a teenager with a drug problem—many clinicians believe that sharing their own similar experiences will display their empathy. Yes, establishing rapport and displaying empathy are critical components of the clinician-patient relationship.

But sharing one’s own personal information is risky: it can cause a role reversal where the patient grows to feel that the clinician needs their care and sympathy; it can blur the lines that separate the professional relationship from a friendship; and it can cause great misunderstandings about future expectations regarding sharing, privacy, and confidentiality. It is entirely possible for clinicians to establish rapport and demonstrate empathy not through sharing their own personal stories, but through active listening, body language, and non-judgmental receptivity to their patients’ stories.

I was just showing them who’s boss.”

Whether you are dealing with an enraged patient or a disgruntled employee, the same professional boundaries apply. In both cases, the goal is effective teamwork. If you lose your temper with a “difficult patient” you risk losing their collaboration in their own care. If you create a hostile work environment or alienate colleagues by flying into a rage or insulting them, you destroy the effectiveness of the healthcare team and diminish the medical care your patients receive. Moreover, such displays of loss of self-control and professional decorum suggest that the clinician is troubled by other issues below the surface that are better dealt with outside the workplace.

Bottom line: professional boundaries exist to inspire and maintain others’ trust in you. That includes colleagues and staff, as well as patients. Anything you do that betrays or undermines that trust can be considered a boundary violation — whether or not it involves sex.

These are only some of the most common misunderstandings. For more on this topic, check out Schenthal’s book, The Physician’s Guide to Professional Boundaries: What you don’t know can end your career. If you have questions about situations not covered here, please let us know so we can address them in a future blog.