Warning Signs Can Save Your Career
Warning signs can save your career … if you notice them in time.
Arthur Conan Doyle based Sherlock Holmes on a keenly observant physician he knew. Not all clinicians are so gifted, but all are trained to spot clues others miss. So why do so many miss signs warning them of impending boundary violations? It’s a mystery most of PBI’s participants puzzle over at some point.
There are three basic reasons clinicians miss warning signs: they don’t know what to look for; they don’t know where to look; and they fail to grasp the significance of what they see. It’s elementary, really.
Three basic reasons clinicians miss warning signs:
1. They don’t know what to look for
2. They don’t know where to look
3. They fail to grasp the significance of what they see.
Knowing What to Look For
A dermatologist can spot a suspicious mole on your face before you’ve taken off your coat because they know what to look for. The problem, of course, is that no one teaches dermatologists or any other practitioners what boundary violations look like as they evolve from innocuous “drifts” into career-ending transgressions.
The first stage is the hardest to spot. You daydream about dating a patient or imagine telling off a colleague who keeps bragging about their successes. Such woolgathering hurts no one and crosses no boundaries, which is why it is called a drift.
It’s not until you find yourself returning to the same thought over and over again or spinning your daydream into a more elaborate fantasy that you’re likely to realize there’s something more serious going on.
If you can’t stop thinking about something or someone, it’s time to stop and think.
When a purely private thought sparks public behavior, the danger of a violation increases dramatically. The action needn’t be dramatic. Anything out of the ordinary is reason for concern, especially if it recurs. If you keep ordering tests for a patient whose diagnosis is clear or calling them after hours to check on them, you need to ask yourself why you are behaving differently with that patient than you do with everyone else.
If you find yourself doing or saying something out of the ordinary, take a minute to stop and think.
Crossings are a Sign of Serious Danger Ahead
A crossing is far more serious than a drift because as the name suggests, it involves actually crossing a professional boundary. The only difference between a crossing and a violation is supposed to be that the former does not cause harm. In reality, you never really know if your action has hurt someone. Say you casually write a prescription for a friend or colleague without taking a history or making a note in their file. Unless you follow up, you simply don’t know whether there was an adverse reaction or other complication. If not, your action was a crossing. But what if your friend is later diagnosed with a serious ailment that went undetected because of your undocumented intervention? Not only are you guilty of a violation, you have also hurt your friend, interfered with their treatment, and seriously damaged your own career.
Any time you realize you have crossed a boundary, whether or not you think any harm was done or anyone complained, you owe it to your patients and yourself to stop and think how best to avoid repeating the mistake.
How do you know if you’ve crossed a professional boundary?
Some boundary violations are explicitly defined by state law (alcohol or drug abuse, sexual misconduct, prescribing controlled substances without a legitimate reason, etc.). So be sure to check your board’s website once or twice a year to review the law and keep up with any changes.
Beyond specific prohibitions, licensing boards can also declare any behavior or interaction a violation that in their judgment harms a patient, the practitioner, the treatment, or a member of the staff. That’s another reason to check your board’s website. A quick review of recent disciplinary actions will alert you to common issues.
Watch for Patterns
A headache and sore throat by themselves don’t indicate Covid-19, but if the patient also complains of a fever and loss of smell, the diagnosis is nearly certain. It’s the cluster of symptoms that’s revealing. The same is true for warning signs. According to PBI founder and President, Stephen Schenthal, MD, MSW, hugging patients is always a risk. It may be a risk worth taking, but it’s important to ask yourself if it’s part of a larger pattern, what Schenthal calls a “cluster of concern.”
“If you have also started talking to patients about your personal life and socializing with them online, perhaps the hug has more to do with your own need for human contact than it does with your patient’s need for comfort,” he suggests. “Whatever is going on, it’s a mistake to ignore the cluster.”
If a cluster of drifts and/or crossings suggest a pattern, stop and consider what’s at the root of the problem.
Knowing Where to Look
A lot of warning signs that might otherwise be obvious get lost in the clutter of everyday life. If a drift or crossing becomes too prevalent, you stop noticing it. You may know that joking about patients or gossiping about colleagues is unprofessional, but if everyone around you is doing it, you stop paying attention. Familiarity breeds contempt and inattention.
Something similar happens when you miss warning signs because you’re preoccupied. In his book, Thinking Fast and Slow, Nobel prize winner Daniel Kahneman puts it this way: “The often-used phrase ‘pay attention’ is apt: you dispose of a limited budget of attention that you can allocate to activities, and if you try to go beyond your budget, you will fail.” If the bulk of your mental energy is being consumed by one particularly difficult case, your ability to pay attention to warning signs will be seriously compromised. The same is true if your attention budget is being dissipated by an endless stream of patients and paperwork. If you don’t believe such preoccupations can blind you to the obvious, check out this famous video about “inattentional blindness.”
Friends and colleagues not consumed by the same distractions can help you catch signals you might otherwise miss. If you are lucky enough to have someone express concern about something you’ve done or said, be sure to pay attention. And don’t dismiss their concern just because they misunderstood what you were doing. It doesn’t matter what you intended. If something looks bad, it is bad. So take misinterpretations seriously and consider what they are telling you about how your behavior appears to others.
If someone mentions a concern about something you’ve said or done, stop and pay attention.
Even if no one has expressed any concerns to you, it’s still worth asking for feedback, especially if you are feeling overwhelmed by work or personal issues. A friendly conversation over coffee can uncover concerns you never even suspected or reassure you that you haven’t missed anything. Many PBI graduates make such check-ins a regular part of their Protection Plan (created during their course) to avoid future problems.
When you feel you have no time for anything, carve out a few minutes to check in with friends.
Warning Signs are too Valuable to Waste
If you are like most practitioners, you probably think you are immune to boundary violations. The hard truth is you are just one patient away from catastrophe. You may have been in practice for decades and assume your spotless record is a sign of incorruptible innocence. It isn’t. You’ve just been lucky, and the next patient may be the one who ends your lucky streak.
Before you decide to ignore all this talk about warning signs, consider a couple of examples of what can happen when you do.
• A psychiatrist who was becoming increasingly friendly with a patient was cautioned by a colleague that she was endangering her objectivity. She didn’t heed the warning. Much later, when the psychiatrist finally realized what was happening and decided to terminate her friend’s treatment, the relationship soured. Hurt and confused, the friend complained to her next therapist, who reported the psychiatrist. The board ruled that the unprofessional relationship had compromised the patient’s treatment. The psychiatrist’s license was suspended for a year and she had to attend a professional boundaries course.
• A pain management specialist who had been reprimanded for sloppy record keeping thought his supervisor was just being overly critical. Then the board got involved. As part of its investigation of an unrelated complaint, the board examined a few of the physician’s records. Concerned by what they found, investigators launched a new investigation and discovered the physician had prescribed opioids on several occasions without documenting their effectiveness. Although the original complaint was dismissed, the physician was placed on probation for his record-keeping violation and is now paying a board-mandated monitor more than $1,000 each month to review his records.
If you think you don’t have to worry about boundary violations, think again.
Just about everyone who has taken a PBI course has kicked themselves for missing warning signs that might have spared them years of grief. It’s too late for them, but you can still save your career — if you pay attention.
The Next Warning Sign Might Just Save Your Career
Stop and think whenever:
- You can’t stop thinking about something or someone
- You find yourself doing or saying something out of the ordinary
- You realize you have crossed a boundary, whether or not you think any harm was done
- You discover drifts or crossings clustering around a core issue
- Someone mentions a concern about something you’ve said or done
- You feel you have no time for anything
- You think you don’t have to worry about boundary violations
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