Inappropriate and Abusive Physician-Patient Relationships

Physicians have ended their careers through inappropriate relationships or abuse of the patient-doctor relationship. The power dynamic between the physician and patient creates a situation where mutual consent is not possible. This is why it is imperative for physicians to maintain boundaries with their patients.

Dr. Larry Nassar, former USA Gymnastics team doctor, who sexually abused hundreds of female athletes and pleaded guilty to federal child pornography charges, was sentenced to 60 years in prison on December 7, 2017. On November 22, 2017, he pleaded guilty in state court to seven charges of first-degree sexual assault and entered another guilty plea a week later to three additional charges of sexual assault. On January 24, 2018, he was sentenced to an additional 40 to 175 years in prison, set to begin after Nassar serves the 60-year federal prison sentence for child pornography.

Another recent case involves a physician who arranged a plea agreement after being charged with four felonies for alleged sexual misconduct with two patients. In summary, one patient claimed she was raped in his office on multiple occasions and, furthermore, he wrote opioid prescriptions for the patient. In a prior incident, the physician had a relationship with another patient that was, according to accounts, mutual and ended without incident.(1)

To protect yourself and the organization from an unfounded claim of inappropriate physical exams, touching, or questions, it is best practice to consider the Garman Guidelines(2):

1. Allow patients to disrobe and dress in private and offer cover gowns and appropriate drapes. (Yes, some physicians do not practice these simple steps.)

2. Have one of your office staff in the room whenever possible, especially during breast and pelvic exams. (I have talked to many physicians who feel this is silly and an added burden on their office staff. However, many women are very offended if these exams are done without another person in attendance. It would be reasonable to have your office nurse ask your patient if she would prefer to have an attendant in the room.)

3. Improve your communication with the patient about the reasons for and methods of examinations. (If you feel a breast examination for axillary lymphadenopathy is necessary for a hand infection, tell the patient why you are doing it.)

4. Avoid any flirtatious behavior toward patients. (Since you are perceived as a “power” figure, the patient may be hesitant to complain directly to you about jokes or other “innocent” behavior.)

5. Ask someone else to review your office procedures regarding physical exams with a view toward avoiding any risky procedures or making necessary changes. (One series of complaints was dealt with by asking the physician’s female office staff to review and change standard examination procedures to avoid future problems.)

John R. Sealy, MD, an expert on the subject of sexual addiction and sexual misconduct by physicians, has provided training to investigators. He provided this valuable missive, entitled “General Truths” to identify known dynamics of sexual misconduct involving physicians:

1. No matter how difficult or boundary testing the patient/client may be, IT IS ALWAYS the professional’s responsibility to maintain appropriate boundaries or, if unable to do so, to refer the patient/client for competent help or counsel.

2. Sexual misconduct usually begins with relatively minor boundary violations. Boundaries include time, place/space, money, gift/services, clothing, and language.

3. Crossing boundaries by a professional is almost always a power differential.

4. The professional must refrain from obtaining personal gratification at the expense of the patient/client. The main source of personal pleasure comes from the professional pleasure gained in helping the patient/client. The fee for professional services is the only material satisfaction a physician should receive directly from the patient/client.

5. No level of training, nor school of medicine, school of law, school of dentistry, or school of psychotherapy confers immunity from sexual misconduct by a professional.

Other “red flags” that push the boundaries of professionalism include:

• You start talking to the patient about the patient’s personal life.

• You check your personal appearance before a particular patient arrives.

• A patient is scheduled at the end of the day to “allow for more time.”

• You allow your staff to go home early while you interact with a particular patient.

• You offer the patient food or drink.

• You exchange gifts or hugs with a patient.

• You offer free care to a particular patient.

• You call the patient at home when the condition does not warrant it.

• You meet the patient outside the office.

An unfortunate circumstance occurs when the script is flipped, and the patient flirts with or tries to seduce the physician. It is common for male patients to make inappropriate comments to attractive female physicians; as well, female patients can and do try to seduce male physicians.(2) When a patient makes an inappropriate comment or flirts, establishing clear boundaries is a priority. To avoid any accusations of impropriety, leave the exam room and find a staff member to witness the remainder of the visit. Another strategy is deflection. Don’t acknowledge the statement and move onto clinical subject matter.(3)

Interestingly, psychiatrists are more likely to be disciplined for sexual boundary violations than their peers. Several factors could increase psychiatrists’ risk of sexual boundary violations. They often work in isolation, out of view of other professionals. They have more personal contact and longer and more sessions with individual patients, hence more opportunity to become intimate with them.(4) Maintaining boundaries and encouraging physicians to ensure following respectful processes with dignity and respect diminishes the opportunities for sexual misconduct or inappropriate relationships.

Excerpted from Physicians and Professional Behavior Management Strategies: A Leadership Roadmap and Guide with Case Studies by Matthew J. Mazurek, MD, MHA, CPE, FACHE, FASA.

References

1. Fisher D. Former Claremont Doctor Pleads Guilty to Assaulting Patient, Could Practice Medicine Again. Union Leader. March 23, 2021.

2. Garman J. Accusations of Sexual Misconduct or Harassment Against Physicians. Medical Board of California. www.mbc.ca.gov/Licensing/Physicians-and-Surgeons/Practice-Information/Sexual-Misconduct.aspx

3. Petrozzello D. How To Handle Romantic Advances from a Patient. ENT Today. August 1, 2013.

4. Gulrajani C. A Duty To Protect Our Patients From Physician Sexual Misconduct. The Journal of the American Academy of Psychiatry and the Law. 2020 June;48(2): 176–180. https://doi.org/10.29158/JAAPL.200014-20