Boundaries

Some regulatory authorities (Colleges) recognize two categories of boundary transgressions:

• Boundary crossings are usually benign and non-exploitative, such as accepting baked goods from a patient to share with office staff. Many boundary crossings are well-intentioned and have a therapeutic intention, such as when a physician holds the hand of a patient who has reached out for support after receiving unpleasant news, or when a physician self-discloses a personal illness with the hope of helping the patient cope with the same illness.
• Boundary violations are harmful to the patient or exploitative, and result from a failure to establish or maintain appropriate limits in the physician-patient relationship. Sexual contact with a patient is always considered a boundary violation. Some other examples include:
  • excessive self-disclosure
  • giving or accepting inappropriate or elaborate gifts
  • probing for inappropriate or irrelevant personal information
  • failing to obtain consent for intimate examinations
  • failing to respect a patient's privacy
  • entering a business or financial relationship with a patient

Sometimes, distinguishing boundary crossings from boundary violations can be difficult. The fact that certain crossings may at times be therapeutically helpful contributes to creating a grey area between what is and what is not considered acceptable by medical regulatory authorities (Colleges). Indeed, successive boundary crossings may create a slippery slope of transgressions that can unintentionally alter the nature of the physician-patient relationship over time or become boundary violations that can harm patients.

Developing a mindful approach to the maintenance of appropriate boundaries may help avoid this slippery slope. The key is to realize that when a boundary is crossed, there may be an accompanying greater risk of harm, exploitation, or other detrimental effects to the patient.¹ The consequences on the patient's well-being may be positive (welcomed supportive touch), neutral (sharing with a patient that your children go to the same school), or negative (holding a patient's hand who is uncomfortable with it, thereby causing anxiety).  Asking the question “Is this in the patient’s best interest?” when crossing a boundary may be a helpful way to remain mindful of this important principle. 

Boundaries may be crossed or violated for many reasons. Human kindness (holding a patient’s hand in support), carelessness (not considering a patient’s history of trauma during an examination), misunderstanding due to a lack of attention or insight (calling a conservative patient who prefers to be addressed as "Mrs." by her first name or calling her "dear") and rarely, self-interest (using the relationship with a patient for financial gain), can all play a role. To prevent misunderstandings and proactively foster a healthy professional relationship with their patients, it is helpful for physicians to reflect upon, devise and universally follow a policy on whether and how they will engage with patients both in the clinical setting and outside of it (for instance on social media or socially within the community). Regulatory authority (College) policies on the matter should inform the standard to observe.

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Intimate procedures or examinations

It is not uncommon for physicians to face allegations that they have violated a boundary while performing intimate procedures or examinations (for example, gynecological examinations). This applies to all physicians, irrespective of the physician’s or patient’s gender or sexual orientation. It is important not to assume that a patient will be comfortable with an intimate examination simply because they are of the same gender as the physician.

While some boundary violations may be deliberate, many are unintentional. Many patients may have experienced trauma including sexual abuse in their past and may find these types of examinations particularly difficult. Knowing your patient and being mindful of such issues, taking the time to explain the nature and purpose of the examination and seeking consent are important for all patients.

To minimize misunderstandings during intimate procedures or examinations physicians should:

• Explain why any questions of a sexual nature are being asked.
• Adequately and clearly explain to patients a procedure or examination, and why it is being performed.
• Obtain a patient's express informed consent for a sensitive procedure or examination by asking if it is ok to proceed after explaining what you will be doing.
• Inform patients that the examination will be stopped upon request.
• If palpation is involved, warn the patient prior to palpating or touching the area.
• Give patients privacy to undress (and dress).
• Avoid moving or removing a patient's clothing without express consent.
• Provide appropriate draping.
• Document any steps taken to specifically address a patient’s concerns about these procedures or examinations.

Offer a chaperone

Chaperones can offer protection and comfort for patients and providers, particularly during sensitive physical examinations.

• Be aware of and follow your provincial regulatory authority (College) policy on offering and providing a chaperone.
• Be aware of and follow your hospital policies around offering and providing chaperones.
• While consent may be implied when a member of the clinical team (e.g. a nurse) is both assisting with the examination and acting as a chaperone, obtain express consent when the chaperone’s only role is that of an observer.

Select a chaperone

• Generally a chaperone should be a trained medical professional (e.g. a nurse).
• If a trained health professional is not available, non-medical staff (e.g. office assistant, receptionist) may substitute, with the patient’s consent.
• Some Colleges offer training courses for office staff to help them understand their roles and responsibilities as chaperones. ³ If you are considering using non-medical staff as chaperones, you will want to investigate any chaperone-training resources available through your College or medical professional association.
• Discuss with your staff the role and your expectations of them as chaperones, especially the need to respect patient dignity and privacy.
• In some cases, it may be reasonable to suggest the patient bring a person of their choosing to the examination, particularly when you do not have the resources to offer a chaperone. The patient should be notified, at the time of booking, of a sensitive examination if you are unable to provide a chaperone.
• Some patients may wish to have a family member or friend present during the examination, in addition to any chaperone you offer. You should generally comply with any reasonable request, where possible and feasible. Consider, however, that not all friends or family members will be impartial and might not fully understand the purpose or steps of the examination.

If the patient refuses a chaperone

• Explain the role of the chaperone as an observer to ensure the patient feels safe.
• If the patient still refuses, consider deferring a non-urgent clinical examination or referring the patient to a health provider who will perform the examination without a chaperone. Make sure the patient understands the potential consequences of deferring a non-urgent examination.
• If the physical examination is necessary to address an urgent or emergent condition and the patient does not consent to a chaperone being present, it is generally advisable to proceed with the urgent examination.
• Document a chaperone’s presence and the patient’s consent or refusal in the medical record.

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Boundary crossings do not always cause immediate or obvious harm to the patient. However, repeated crossings or progressively bolder minor ones may become a "slippery slope" resulting in a more serious boundary violation.

Romantic relationships

Romantic and sexual relationships between physicians and current patients are inappropriate and therefore forbidden. Due to the power imbalance, even if the patient consents to or initiates a sexual relationship with the physician, it is considered sexual abuse and is forbidden by regulatory authorities (Colleges).

In instances where romantic relationships and sexual contact start after the doctor-patient relationship has ended, the physician may still be found to have committed professional misconduct. In determining the propriety of a romantic or sexual relationship between a physician and a former patient, a number of factors will be considered that may include the length and nature of the doctor-patient relationship, the extent to which the patient has received psychotherapy (if any), and the vulnerability of the patient.

Physicians should be familiar with their College guidelines or policies on boundaries. For example, some Colleges have guidelines on specific time periods required between the formal termination of a doctor-patient relationship and the initiation of a personal one. Some Colleges also stipulate that in certain circumstances (i.e. if psychotherapy was provided), it is never appropriate to enter into a personal relationship with a former patient.

All Colleges have “zero tolerance” with respect to sexual abuse. If you are in doubt whether beginning a romantic or sexual relationship with a former patient would be considered a boundary violation, you may wish to seek advice from the CMPA.

Dual relationships — Professional and social

Physicians may well have patients with whom they socialize or have friendships. Many physicians, particularly those working in small communities, will have patients in their social networks. It can be very difficult to maintain strict professional boundaries when patients attend the same religious institution, shop in the same stores, eat at the same restaurants, attend the same social functions, or play the same sports. These issues can be challenging for physicians, however, it is the responsibility of the physician to maintain appropriate trust, respect, and professional boundaries.

In these cases, physicians should still be conscious of the potential for boundary crossings and, as much as possible, separate their personal and professional obligations. The closer the relationship is between the physician and the patient, the greater the risk of a perceived boundary violation. Questions you can ask yourself to assess whether boundaries are being blurred include:

• During clinical encounters do I encourage conversations about non-medical or social activities for my personal benefit?
• How would a neutral observer view this arrangement?
• How does/could the patient view this?
• Do I feel I must keep social interactions with the patient secret?

Treating family and close friends

Treating family, friends, or staff may compromise a physician’s objectivity and judgment. Of particular note, consider that most Colleges have policies regarding prescribing medications to family or close friends, especially narcotics, controlled drugs or substances, monitored drugs, cannabis for medical purposes, or any drugs or substances that are addicting or habituating.⁴ Most Colleges have policies that prohibit physicians from treating or prescribing medications for family members, except for minor conditions or in emergencies when another health provider is not available. If ongoing care is required the family member or close friend should be referred to another health professional.

Business transactions

Physicians should avoid entering into business deals with patients. Dual relationships with patients can result in a conflict of interest, lessen clinical objectivity, and ultimately may impair clinical judgment. Due to the power imbalance between the physician and patient, patients may feel pressured to enter into a personal transaction with their physician out of fear that refusing might jeopardize their relationship with the physician or the quality of care they will receive. Bringing your personal life into the relationship with a patient carries the risk of impinging on the quality of medical care and has potentially serious consequences.

Power of Attorney requests from patients

Physicians may be asked to act as a patient's power of attorney. In most cases, physicians should respectfully decline these requests, especially when another suitable individual is reasonably available to take on the role.

Self-disclosure

While it may be appropriate in some circumstances to share with your patients limited general information about yourself (for example, a favourite sports team, the fact that you have a pet) it is generally improper to disclose personal information or share intimate details about your personal life (e.g. relationship, financial, or health problems).

It is unacceptable for physicians to discuss their sex life or sexual relationships with patients. Not only can divulging intimate personal information make patients uncomfortable, it could lead the patient to misunderstand the nature of the relationship and see it as a friendship rather than purely professional.

Gifts

After receiving care, it is not unusual for patients or their family members to thank physicians by giving gifts. While such a gesture is often benign, it can become a boundary violation — depending on the circumstances and the nature of the gifts. Accepting gifts or other financial benefits may create an expectation that the patient will be afforded special status and that the favours will be reciprocated.

If gift-giving is part of a pattern of behaviour that suggests the patient is looking for more than just a professional relationship with the physician, or if the gifts are inappropriate or expensive, is wise to talk about it with the patient. The physician should explain that it is inappropriate to accept gifts for medical services, or to form a personal relationship with patients.

When a patient offers a gift of significant value or gives multiple smaller gifts, the physician should sensitively explain why the gifts cannot be accepted. These discussions should be documented in the patient's medical record.

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