Introduction

A boundary violation occurs when a physician fails to abide by the professional limits of a relationship with his/her patient. The College of Physicians and Surgeons of Newfoundland and Labrador views boundary violations as a continuum from sharing personal information to making sexualized comments to becoming intimately involved with a patient.

Each and every physician-patient relationship is a relationship of trust, where the physician is in the position of the trusted person on whom the patient is dependent. It is the responsibility of the physician to recognize the boundaries of a physician-patient relationship and to avoid boundary violations. It is also the responsibility of the physician to recognize that patient participation in boundary violations does not lessen a physician’s responsibility to avoid boundary violations.

By this policy, CPSNL is stating its position that allegations of boundary violations will be the subject of investigation by the College and may lead to disciplinary measures including suspension of a physician’s licence. CPSNL also wishes to categorically state its position that sexual involvement between a physician and his/her patient is never acceptable.

This policy is intended to be an explanatory and illustrative supplement to CPSNL’s Code of Ethics (By-Law No. 5).

Examples

The following is a non-exhaustive list of examples of boundary violations:

· Any behaviour, gesture, expression, or comment that is sexualized, seductive or sexually-suggestive to a patient, made in person, by telephone, text message, or through social media,

· Inappropriate disrobing or draping practices that reflect a lack of respect for the patient’s privacy,

· Failing to provide privacy when a patient is undressing or dressing,

· Criticism of a patient's sexual orientation or activities,

· Making comments about the patient's potential sexual performance, except when the comments are relevant to the management of the medical concern that the physician is treating,

· Requesting details of sexual history when not medically indicated,

· Not explaining the medical purpose and appropriateness of an examination of the breasts, genital area and anal area or failure to obtain express consent for such examinations,

· Using unorthodox examination techniques, including touching a patient’s body in a manner which does not respect the dignity of the patient,

· Kissing and hugging of a sexual nature,

· Sustained or repetitive touching of a patient’s body for any purpose other than appropriate physical examination or treatment, or where the patient has refused or withdrawn consent, or would have withdrawn consent if the patient appreciated that such touching did not constitute appropriate physical examination or treatment,

· Socializing with a patient for the purposes of developing an intimate relationship,

· Any form of sexual activity with a patient, even if initiated by the patient and/or consented to by the patient.

Physicians and patients should have the option of having a third party present at any examination. Physicians should ensure that patients are aware of this option, regardless of the physician/patient genders.

A physician must NOT:

· terminate a physician-patient relationship in order to pursue a sexual or personal relationship,

· initiate any form of sexual advance towards a previous patient where the physician uses or exploits trust, knowledge, emotions or influence derived from the previous physician-patient relationship, or

· engage in a sexual or personal relationship at any time (including after the conclusion of a physician-patient relationship) where the physician provided the patient with psychotherapy of any form.

A physician who is uncertain about his/her obligations should contact the College.

Precautions in Practice

All physicians should take into consideration the following precautions:

· Ensure any remarks or questions are not construed as demeaning, seductive or sexual in nature.

· Explain why a question relating to sexual matters is being asked.

· Keep in mind that any type of touching of a patient outside of the physical examination has a risk of being misinterpreted by the patient.

· Consider using a chaperone for the comfort of the patient and also to protect the physician from unfounded allegations.

· Provide privacy to dress and undress and a gown or drape.

· Allow the patient to remove or replace their own clothing.

· Explain the reasons for an examination and the scope of the examination.

· Be mindful of cultural preferences.

· Avoid crossing non-sexual boundaries such as self-disclosure.

Contact the College if questions or concerns arise.

Duty to Report

If a physician, on reasonable grounds, believes that another physician has committed a boundary violation, the physician has an ethical and legal obligation to notify CPSNL.

This obligation is recognized in the Canadian Medical Association’s Code of Ethics, Item 48, which states:

“Avoid impugning the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional conduct by colleagues.”

In addition, subsection 41 (1) of the Medical Act, 2011 states:

“A medical practitioner who has knowledge, from direct observation or objective evidence, of conduct deserving of sanction of another medical practitioner or a person who is registered on the education register shall report the known facts to the registrar.”

Disciplinary measures

All allegations of boundary violations will be investigated by CPSNL.

CPSNL maintains full discretion over what it considers a boundary violation and what the appropriate penalty will be for each case. As patient safety must come first, CPSNL may place conditions or restrictions on a physician’s practice while the investigation is ongoing.

Sexual misconduct boundary violations are recognized by CPSNL as being amongst the most severe categories of professional misconduct. Where such misconduct is admitted or proven, it should be anticipated that severe penalties will be imposed, including substantial suspension from practice or, in the most serious cases, being struck from the register.

Approved by Council: June 13, 2015

Previous Version (Guideline): April 16, 2008