In many cases, the physician-patient relationship is guided by the Hippocratic Oath (translated from 1923 Loeb edition). The traditional Oath states, “Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free.” Physicians must possess strong skills in self-monitoring and self-reflection. They must also enforce practice policies to prevent, detect, and stop the recurrence of physician sexual misconduct.
It is crucial to report such misconduct to the appropriate regulatory and legal authorities without fear of repercussions from colleagues or superiors. Additionally, comprehensive training and review about how to confidently initiate and conduct sensitive examinations with patients and effectively communicate during such exams.
Related: Guidance on Professional Boundaries and Sexual Misconduct
Use of qualified chaperones
Physician and patient interactions should promote supportive and respectful environments that uphold the dignity of patients even when dealing with sensitive issues. This can be accomplished by providing appropriate gowns, having private facilities for undressing, utilizing draping of sensitive areas, and clearly explaining the various components of the physical examination.
Additionally, having chaperones available is instrumental in fostering a professional and considerate atmosphere. Physicians are encouraged to:
- Establish a policy that allows patients to request a chaperone and ensure effective communication of the policy to patients.
- Always honor a patient’s request for a chaperone.
- Designate an authorized member of the healthcare team to serve as a chaperone, with clear expectations that chaperones will maintain professional standards of privacy and confidentiality.
- Generally, employ a chaperone even when a patient’s trusted companion is present.
- Provide opportunities for private conversations with the patient without the chaperone present. Physicians should limit inquiries or history taking of a sensitive nature during a chaperoned examination.
Recommendations for intimate exams
Good professional conduct starts with respectful, clear communication. It’s important to maintain open lines of communication throughout any examination that takes place without general anesthesia. Every exam should include the following explanation points:
- The medical necessity of the exam
- What the exam will involve
- Point out any discomfort the patient may experience
- Discuss expected benefits, potential risks, and findings
During intimate examinations, additional measures should be taken to provide a comfortable and considerate environment for the patient. These measures include:
- Use of appropriate gowns and draping
- Perform only after patient consent
- Perform with the minimum amount of contact to obtain a diagnosis
- Use appropriate chaperones and have policies in effect to report misconduct
Boundaries for respectful communication
The advent of social media and the availability of personal information online requires physicians to take additional measures to ensure appropriate physician-patient boundaries. This includes limiting the disclosure of personal information, refraining from posting identifiable patient information, and separating personal and professional content online to prevent the blurring of boundaries.
Prevalence and underreporting of physician sexual misconduct
Despite increased efforts to encourage patients and other medical professionals to report incidences of physician sexual misconduct, many occurrences still go unreported. In one study, experts estimated that only 1 in 10 cases were reported.
The Federation of State Medical Boards (FSMB) surveyed 2,000 adults and found that only a third of patients who experienced physician misconduct reported the incident or filed a complaint. The underreporting occurs due to multiple factors including:
- A lack of knowledge of how to file a complaint
- The fear of retaliation by the physician
- The distrust in institutions such as the state medical boards and hospitals
- An unwillingness to relive the trauma
- Uncertainty over whether a traumatic event was truly unprofessional and unethical
- Complicity in the violation to obtain drugs or fear of being dropped as a patient
Understanding the different types of sexual misconduct
Sexual harassment is defined as “unwanted sexual advances, propositions for sexual favors, and other verbal or physical conduct of a sexual nature.” An environment tolerant of sexual harassment makes it conceivable that sexual misconduct may occur. Setting appropriate professional boundaries helps to prevent situations that can be misconstrued as physician sexual misconduct.
Boundary crossing is a modification of the professional boundary. It lacks the motive of exploitation, such as accepting a gift of modest value. However, a boundary violation involves a more black-and-white violation such as publishing a journal article displaying confidential patient information. When the violation exploits the physician-patient relationship in a sexual manner, the FSMB classifies this as sexual misconduct.
Avenues to report physician misconduct
When physician misconduct is observed, early reporting allows appropriate interventions. These aim to prevent recurrence or lessen the risk of more egregious behavior to occur. When someone observes behavior contrary to professional standards, take the following steps.
- To assess patient welfare and take any necessary remedial action, report misconduct to the appropriate clinical authorities.
- When patient safety is jeopardized, report misconduct directly to the state medical board.
- When initial reporting fails to change or stop the behavior, attempt to report the misconduct to a higher authority.
- During the reporting, protect patient privacy to the greatest extent possible.
Understanding trauma-informed care
Trauma-informed care is a model for approaching patients who have experienced past trauma. It develops a comprehensive approach to provide effective healthcare services with a healing orientation. The goals of trauma-informed care seek to realize the widespread impact of trauma, understand paths for recovery, and avoid re-traumatization.
To accomplish a trauma-informed approach, healthcare organizations must recognize and support the six core principles.
- Safety. The organization must prioritize the physical and emotional safety of its staff and patients.
- Trustworthiness and transparency. Decisions must be made with complete transparency and geared towards building trust.
- Peer support. Individuals with similar experiences should be incorporated and viewed as integral parts of the delivery of services.
- Collaboration. Respect and value input from all members to improve the organization.
- Empowerment. Recognize and build upon the strengths of patients and staff to facilitate healing after trauma.
- Humility and responsiveness. Identifying and addressing biases and stereotypes to provide improved services.
Related: Intercultural Competence and Patient-Centered Care
The awareness and knowledge of how to handle situations involving physician sexual misconduct can aid in increasing the frequency of reporting. Understanding professional boundaries are important in preventing the misinterpretation of a physician interaction and preventing an interaction from crossing boundaries.
Incorporating courses into the curriculum of medical schools, residency programs, and continuing education is important in reducing the occurrence of physician misconduct and facilitating the reporting of incidents.
