Professional Documents
Culture Documents
Physician-Patient Relationship
Glen O. Gabbard, MD, Carol Nadelson, MD
THE SUBJECT of professional boundaries (and boundary violations) has received a great deal of recent attention in
the psychiatric literature.1-5 The emphasis on defining guidelines for professional
conduct has expanded beyond the confines of ethics committees and has
worked its way into licensing boards
charged with disciplining physicians
whose behaviorjeopardizes
the well-being of patients. The Massachusetts Board
of Registration in Medicine,6 for example,
has recently issued detailed guidelines
on such matters as self-disclosure, dual
relationships, sexual relationships with
patients, and other professional boundaries to help define for the public and for
the profession the parameters of professional conduct in the practice of psychotherapy by physicians. While specialists in psychiatry have been debating the pros and cons of issuing such
so ex-
involvement.1,3-5
Hence,
gressions.
Sexual Boundary Violations
Six studies813 have sought
to deter
mine the prevalence of sexual miscon
duct in the physician-patient relation
ship (Table).
A comparison of the US studies with
fess. In essence,
true
we
Sample Size
Source, y
Kardeneretal,81973
1000 male
physicians
5574
Gartrelletal,91986
Gartrelletal,101992
10 000
Specialties
Gynecology, psychiatry, internal medicine,
surgery, general practice
Psychiatry
Family practice, internal medicine,
gynecology, surgery
All
975
ethical."20*274
Men
Women
Acknowledging
Contact, %
Acknowledging
Contact, %
Not applicable
46
12
7.1
26
3.8(8.1*)
0.3
(4.3*)
4t
ENT
3.1
10
69.5
specialties
Gynecology,
Gynecology
Rate, %
78
in the
study.
Regarding
tween former
sexual
relationships be
patients and physicians,
physician-patient re
lationship. The physician can thus be
viewed as an all-knowing parent, and a
on the
other hand, "gains power only by virtue
of being surrounded by boundaries that
the physician cannot cross without egregiously violating moral rules.',24(p62)
The combination of transference and
the power imbalance between the phy
sician and the patient makes mutual con
sent, in the usual sense, highly ques
tionable. As Johnson25*1559' has stressed,
those who argue that mutual consent is
possible between physician and patient
stand "in sharp contrast to the implied
presumption of disproportionate profes
sional control underlying the AMA's
opinion on sexual misconduct." Finally,
studies find that there is the potential
for considerable harm to the patient as
a result of such sexual relationships.2628
Dual Relationships
An essential element of the physician's
role is the notion that what is best for
the patient must be the physician's first
priority. Physicians must set aside their
own needs in the service of addressing
the patient's needs. Other kinds of re
lationships that coexist simultaneously
with the physician-patient relationship
have the potential to contaminate the
physician's ability to focus exclusively
on the patient's well-being and can im
pair the physician's judgment. As noted
herein, patients can transfer residual
longings from other relationships onto
the person of the physician, and they
can view the physician as parent, spouse,
lover, adversary, or friend. If the phy
sician tries to maintain both roles with
the patient, objective decision making
may be jeopardized. For example, fi
nancial relationships or business trans
actions may lead to resentment or de
pendency that interferes with the phy
sician's ability to be empathie, sensitive,
and selfless in the physician-patient re
lationship. Similarly, romantic ties or
intimate friendships with patients may
make it difficult for the physician to con
front noncompliance with treatment or
to bring up unpleasant medical infor
mation. The long-standing practice of
referring family members to another
physician grows out of similar consid
erations regarding compliance and com
promised objectivity.29 Even in the case
of a rural family practitioner who treats
physician-patient relationship.
Second, there is often a secret quid pro
quo involved in performing services or
bestowing a gift. As implied by the say
ing, "There is no free lunch," expecta
tions arise from gifts. The same can ap
ply to the physician who gives patients
gifts or refrains from charging a fee for
a particular patient. Although done with
the best of intentions, the patient may
feel burdened by a sense of obligation
that can never be openly discussed with
the physician. Similarly, physicians who
receive expensive gifts may feel an ob
ligation that influences their clinical
of the
the
Language
An essential component of professional
conduct is respect for the patient's dig
to
gressively
to
more
extreme
boundary
PREVENTION OF BOUNDARY
VIOLATIONS
The key to preventing boundary vio
lations lies largely in education, although
certain physicians whose characterological defects lead them to this behavior
may not be deterred by such efforts.
Medical students and residents should
be taught the concept of professional
conduct in conjunction with learning in
terviewing and physical diagnosis. Sen
sitivity to professional boundaries should
be as routine as auscultating the chest.
These issues should be discussed, not
exclusively in the context of ethics
courses, but in all clinically oriented
courses. They are the fabric of the phy
Physical Contact
Physical contact outside the context
of the physical examination varies
widely. Some physicians routinely shake
the hands of their patients on greeting
them, a practice that is well within the
scope of professional conduct. Others
sician-patient relationship.
1992;46:544-555.
SH, Fuller M, Mensh IN. A survey of
8. Kardener
Crossing the Boundaries: The Report of the Comon Physician Sexual Misconduct. VancouPrepared for the College of Physicians and
Surgeons of British Columbia; November 1992.
12. Wilbers D, Veensstra G, van d Wiel HBM, et al.
Sexual contact in the doctor-patient relationship in
mittee
ver:
feelings.
In the midst of
our
enthusiasm for
in the doctor-patient relationship: discussion document for the profession. Newslett Med Council N
Z. 1992;6:4-5.
22. Equal Employment Opportunities Commission.
Guidelines on discrimination because of sex. Federal Register. 1980;45:7467-74677.
23. Goleman D. Sexual harassment: about power,
not sex. New York Times. October 22,1991:B5-B8.
24. Brody H. The Healer's Power. New Haven,
Conn: Yale University Press; 1992.
25. Johnson SH. Judicial review of disciplinary action for sexual misconduct in the practice of medicine. JAMA. 1993;270:1596-1600.
26. Feldman-Summers S, Jones G. Psychological
impacts of sexual contact between therapists or
other health care practitioners and their clients.
J Consult Clin Psychol. 1984;52:1054-1061.
27. Williams MH. Exploitation and inference: mapping the damage from therapist-patient sexual involvement. Am Psychol. 1992;47:412-421.
28. Kluft RP. Incest and subsequent revictimization: the case of therapist-patient sexual exploitation, with a description of the sitting-duck In: Kluft
RP, ed. Incest-Related Syndromes of Adult Psychopathology. Washington, DC: American Psychiatric Press; 1990:263-287.
29. La Puma J, Priest ER. Is there a doctor in the
house? an analysis of the practice of physicians'
treating their own families. JAMA. 1992;267:1810\x=req-\
1812.
30. Chren MM, Landefeld CS, Murray TH. Doctors, drug companies, and gifts. JAMA. 1989;262:
3448-3451.
31. Bradshaw S, Burton P. Naming: a measure of
relationship in a ward milieu. Bull Menninger Clin.
1976;40:665-670.