UNITING PHYSICIANS & PATIENTS AS A VOICE IN HEALTH CARE

Archive for January 8th, 2011

Role Reversal: When the doctor becomes a patient

Saturday, January 8th, 2011

The route to assuming the mantle of medical authority is a familiar one: the weeding-out process and survival of pre-medical studies, the plodding discipline of medical school, and the special expertise of post-graduate medical education all prepare the budding doctor to be adept at making diagnoses and rendering treatments. In the metamorphosis to medical professionalism, doctors may gradually come to view patients as a drag on treatment adherence; their individual wants and peculiarities are seen as psychological obstacles to optimal treatment outcomes. So, there are separate worlds of doctors and of patients.

But what happens when those worlds intersect—when the doctor is a patient? It is well known that physicians frequently have difficulty accepting the patient role for themselves and following recommendations and guidelines for care they recommend to their patients. Yet, arguably, public safety may be at issue when physicians don’t seek appropriate medical care or fail to follow through on prescribed treatment. This is particularly true for treatment of disorders related to mood and cognition—depression, drug addiction, alcoholism, and dementia.

These maladies affect physicians to at least the same degree as the general population; indeed, a recent study found that the chances of dying by suicide are about 70 percent higher for male physicians than for men in the general population, and between 250 percent and 400 percent higher for female physicians than other women (T. Hampton, JAMA, 2005, 394:1189–1191). Untreated depression in physicians is such a serious concern that American Foundation for Suicide Prevention issued a consensus statement in 2003 stressing the need to change professional attitudes and institutional policies to encourage physicians to seek help when needed.

Barriers to treatment

Why do physicians resist medical treatment, especially for mental and substance use conditions? To understand this, we must look at a number of special issues for doctors in addressing their own health care needs:

  • Personal views toward seeking medical or mental health care;
  • The stance of other doctors toward them as patients and professionals;
  • The laws governing reporting impaired physicians to the state;
  • The attitudes of systems in which doctors practice; and
  • Medical insurance and payment matters.

Attitudes toward seeking care. Doctors strive to avoid shame and appearing weak to their patients and medical colleagues, an attitude that is reinforced by their medical training and acculturation. In addition, doctors are aware of medical uncertainty in predicting the outcomes of a given medical condition, and this awareness may contribute to delaying establishing a diagnosis for themselves. Also, they are used to being in charge of diagnosis and recommending and evaluating courses of treatment. So, when doctors are ill, they want to maintain control of the medical decision-making process.

Perhaps the biggest obstacle for physicians who need professional help has to do with trust, which is crucial to all healthy physician-patient relationships. Trust is based on the expectation that the treating doctor will remain engaged as the physician-patient’s advocate in the ongoing work of diagnosing illness, making recommendations for appropriate care, and negotiating and implementing effective treatment strategies. Too many doctors seem to rule out this kind of physician-patient relationship for themselves because of the additional complexity that colleagues treating colleagues introduce into the relationship.

Attitudes of physician colleagues. Like most patients, physicians ask the question, “What would you do, doctor, if you were in my shoes?” But unlike non-physician patients, they are concerned that their treating doctors will treat them deferentially or abandon them as patients if they share their weaknesses, self-doubts, or secrets with a colleague.

Reporting requirements. Doctors may avoid seeking medical or psychiatric care because of legal obligations for physicians and health care professionals to report impaired doctors to the state. Because of the need to protect patients and the public, physicians and other health care personnel in Minnesota are required by law to report professional colleagues to their respective licensing boards if they suspect impairment or unprofessional conduct with patients.

Attitudes of health systems. The culture of the health care system in which a physician practices may create a barrier to seeking treatment for mental or substance abuse problems. Increasingly, physicians are employees of large clinic corporations, and as such, they fear being viewed as disposable when perceived by the corporation as unproductive or a liability to the clinic’s reputation.

Medical insurance and payment matters. Health insurance plans that limit physicians” access to treating physicians may pose barriers to getting treatment. For example, physicians whose access to medical care is restricted to physicians in their medical facility or insurance plan may be reluctant to seek in-house treatment for mental health conditions. In addition, they are rightly concerned about issues of privacy and confidentiality, as they know that medical and claims data may be passed on rather easily to other parties.

Steps to obtaining treatment

What steps can physicians take to improve access to needed medical services for themselves or their colleagues?

Seek and accept help from colleagues. Oftentimes help or an intervention is prompted by patient complaints about a physician’s inattention or inappropriate behavior. Thankfully, colleagues and clinic administrators are becoming more comfortable encouraging their medical colleagues to get help from other doctors and professionals, while saving face with clinic personnel and patients. Usually a doctor’s work colleagues are the first to celebrate and praise the physician for getting help and to offer support, whatever the illness or malady.

Most organizations assist their physician and health care colleagues in obtaining help with alcohol and drug problems. As these beneficial efforts are expanded, it is vital that the clinic physician or health care professional be allowed to and encouraged to seek professional help outside of the clinic provider network. This means extending work-based health care coverage to cover the costs of out-of-network care so that physicians and other health care personnel need not be treated by the same doctors with whom they work each day.

Diversion program for impaired physicians. Doctors who get appropriate medical attention for psychiatric, substance abuse, neurological, or medical conditions related to physical or cognitive impairments can set up a plan of evaluation, care, and monitoring with the Minnesota Health Professionals Services Program (HPSP). Physicians or other health care professionals eligible for and accepted by the HPSP diversion program can usually remain in practice when they adhere to their negotiated plan of care with HPSP. More information about HPSP and the Minnesota Board of Medical Practice may be found at www.hpsp.state.mn.us and www.bmp.state.mn.us.

Treating physicians who file quarterly reports to HPSP must attest to the physician-patient’s compliance to a plan of care monitored by the HPSP staff. Thus, HPSP diversion provides a pathway to treatment for impaired physicians, but HPSP monitoring introduces a level of scrutiny that can detract from open disclosure and partnership in the doctor-patient relationship.

The treatment relationship

A healthy doctor-patient relationship requires the treating physician and the physician-patient to consider their comfort levels about the quality of their communication and to share their views about the following aspects of therapy:

  • Why and how the patient is here at this time;
  • Outside shared relationships and potential conflicts of interest or triangulated relationships, if any;
  • Issues concerning data and communication privacy and privilege;
  • How the diagnostic examination and test results will be interpreted and shared with the patient and others;
  • The rationale for all tests and examinations;
  • The expected frequency and duration of appointments;
  • Negotiations with the patient concerning care plan and progress; and
  • The doctor’s treatment planning recommendations.

If either the treating physician or patient is uncomfortable during this process, this discomfort should be discussed, understood, and resolved in short duration. If this is not possible, the doctor should recommend referral of the patient to another physician.

The physician-patient. Although doctors often experience anxiety when switching their role from the treating authority to the recipient of medical care, it is not true that doctors make poor patients because they know too much. Like most patients, doctors greatly appreciate frankness and honesty from their treating physicians.

Physician-patients should view their tendency to self-prescribe and their failure to adhere to a plan of care with their doctor’s advice as an occupational hazard. They should inform their treating physicians when they have disagreements or doubts about receiving “formal” medical care or when they disagree with the care recommendations.

The treating physician. The treating doctor needs to be fully aware of the physician-patient’s attitudes toward being ill and being treated for illness. To set the proper tone and structure for the physician-patient relationship, the doctor should treat the patient in the usual clinical setting. Treating doctors must maintain their professional boundaries with their patients who are professionals. In this regard, the general rule is, “Why would I consider treating this patient differently than any other?” A warning signal is the thought (whether expressed or not), “I don’t do this with other patients, but for you, because you are a doctor, I will.”

Treating doctors may feel angry with their professional patients. They may not understand this anger. It may be born of anxiety for the fate of the patient, identification with the patient, or a feeling that the patient has behaved stupidly or brought on his troubles; or it may come from the doctor-patient’s nonadherence to treatment recommendations.

Changing attitudes, policies

Increasing media attention to and public dialogue about health issues such as depression and other mental health issues, alcoholism, and chemical abuse highlight the need for physicians to seek treatment for these conditions. Physicians often are more reluctant than their patients to seek treatment for any condition that may be associated with impairment or social stigma, for reasons related to both professional and personal circumstances and characteristics.

The American Medical Association has recommended that professional attitudes and institutional policies be changed so that physicians with health problems can more easily seek and find appropriate medical care. This entails a clear understanding between treating physicians and their patients about special aspects of the doctor-professional relationship; clarity of legal requirements concerning reporting impairment; and access to physicians and mental health professionals outside of the doctor’s clinic.

Lee H. Beecher, M.D., is a clinical associate professor in the Department of Psychiatry at the University of Minnesota, immediate past president of the Minnesota Physician-Patient Alliance (MPPA), and a psychiatrist in private practice in St. Louis Park.

The author references Michael H. Gendel’s article “Treatment Adherence in Physicians” (Primary Psychiatry, Vol. 12, No. 6, June 2005, pp. 48-54) in preparing this article.

Sexual Boundaries: The Conduct, the Code and the Consequences

Saturday, January 8th, 2011

Abstract

Health services professions agree that sexual relations between treating clinicians and their patients are harmful and should not be tolerated. Minnesota law and regulations encourage identification of offending clinicians in order to protect the public. Regulatory agencies such as the Minnesota Board of Medical Practice seek to stop licensed professionals from engaging in sexual behavior with patients and also, when feasible, to restore medical professionals to competent practice. The authors recommend individualized psychiatric assessment and therapy for physicians who violate professional standards.

The term “professional sexual misconduct,” often used to refer to physicians’ sexual boundary violations with patients, is somewhat of a misnomer because there is simply no professional justification for doctors or other clinicians to engage in sexual behavior with their patients. Sex between physicians and patients, including flirting and seductive talk, clearly undermines patient trust, violates the fiduciary responsibilities of physicians to patients, isolates physicians from their medical colleagues, and cripples the therapeutic power of the doctor-patient alliance. So the zero-tolerance standard for sexual misconduct is appropriate and in no way puritanical or prudish. The standard is based on a broad consensus that the medical profession, policymakers, and the professional licensing boards must be empowered to protect the public. Despite agreement about these standards, physician-patient sexual relationships continue to occur. Although their prevalence is not fully known, published surveys have indicated that 9% of doctors acknowledge having had sexual contact with patients in the past, and 23% of patients report past sexual contact with physicians.(1)

It is not believed that doctor-patient sex is on the rise in Minnesota, despite a lack of periodic, confidential surveys of Minnesota physicians about sexual involvement with their patients. Nonetheless, heightened public and professional awareness here and nationwide is leading to better identification of suspected cases.

The Slippery Slope

Doctors who serve as reviewers and consultants for the Minnesota Board of Medical Practice (BMP), which investigates such reports, note the slippery slope of how boundary crossings progress to boundary violations. Both physician and patient, knowingly or unknowingly, may allow a relationship to progress toward one that is inappropriate.(2) A “grooming sequence” ensues when patient and physician begin addressing each other by first name. The professional persona of the examining room fades at the door, physician self-disclosure turns into doctor revelations of personal and sexual feelings, office visits may be extended while the length of other patients’ visits is disregarded, and physician record keeping deteriorates for the patient with which the physician is involved. Physical contact begins with hugs and kisses on the cheek; the physician may discuss other patients with the special patient; they begin meeting at a restaurant outside the office; the physician stops charging the patient, and/or the patient’s bill mounts without discussion of it or attempts to collect on it; office visits for the special patient are moved to the end of the day; and dating begins.

It is not uncommon for the patient to wish to continue the “new” relationship. The patient at times will threaten to turn the doctor in to the medical board or notify his or her clinic authority if the doctor threatens to end the relationship, and very often the doctor becomes anxious about maintaining the secret. Most complaints to the BMP occur after it becomes clear to the patient that the doctor is unwilling or unable to sustain or terminate the relationship.

Such complaints are relatively rare. The Minnesota BMP, which regulates the state’s 18,000 physicians, reported that 20 (2%) of its 941 total complaints about physicians and other health care providers it oversees in fiscal year 2004 alleged that a licensee had engaged in sexual activity with a patient.(3) Complaints of sexual misconduct are automatically referred to and investigated by the Minnesota Attorney General’s office. Investigation into the complaint often involves the patient, doctor, doctor’s staff, and other parties. A doctor’s medical record also is carefully scrutinized.

Appeal to an Outside Authority

Most physicians encourage patients to inform them or their associates when grievances or questions arise about their care. However, approaching a doctor about sexual issues, especially when it involves the doctor’s own behavior, or when a patient-doctor relationship has already become sexual is not often a realistic option for patients or their families. Patients already feel exploited by the doctor, and they commonly believe that the doctor’s colleagues will not be receptive to their concerns. Patients who have discussed their experiences with representatives from the BMP or investigators from the attorney general’s office or during psychotherapy often report that they expect to be humiliated, put off, or bullied by the doctor because so much is at stake for the doctor.

Indeed, the doctor is responsible for the conduct of a doctor-patient relationship when sex occurs.(4) Thus, patients who perceive or experience unwelcome or invited sexual behavior from their doctor cannot in most cases work this out with the doctor. Moreover, when the patient does notify the doctor’s clinic or employer who determines that the patient’s complaint is credible, the doctor is often suspended from clinical practice and may be terminated as an employee.(5) Patients in such cases need special attention from the clinic to cope with their trauma and needs for care continuity. Doctors should immediately seek legal counsel and consult their professional liability insurance carrier, which may or may not indemnify sexual violations with patients.

To address the inherent imbalance of power in the doctor-patient relationship, Minnesota passed legislation in 1996 not only prohibiting physician conduct that is sexual or that may be reasonably interpreted by the patient as sexual and verbal behavior that is seductive or sexually demeaning to a patient, but also identifying the grounds by which a physician may lose his or her license to practice medicine.(6)

Initiating a Complaint

When a patient, the patient’s advocate, or another professional contacts the medical board alleging that a physician has exhibited inappropriate sexual behavior, talk, or innuendo, there is an assumption that the complaint has merit. Moreover, if the doctor has already been the subject of past complaints to and/or investigations by the BMP for any reason, the BMP will review the previous cases as well as the new complaint.

The professional literature reports that sexual abuse claims more often than not have a basis. But there are situations in which physicians may be falsely accused of substantial sexual boundary violations with patients. These may involve misinterpretation of remarks made in haste. Also, patients may be angry with or frightened by the doctor for reasons that are not immediately apparent. Frequently, such cases are associated with unpaid bills, a perception that the doctor is not sensitive to the patient’s concerns, and in some cases, the false belief that the doctor is in love with or desires to establish an intimate relationship with the patient.(7) For that reason, staff from the BMP and the attorney general’s office are trained to consider such situations and to not rush to judgment about the facts or presume that the doctor is guilty when they investigate a complaint.

In 5 states, sexual misconduct by professionals is now addressed under civil statute, and in 16 states, including Minnesota, sexual misconduct by health professionals is considered a criminal offense as well.(5)

Treatment and Accountability

There is no single diagnostic profile or set of psychiatric criteria to describe physicians who become involved in sexual relationships with their patients. In many cases, physicians—and sometimes patients who cross sexual boundaries—are using/abusing alcohol, illicit drugs, or prescription medications; have untreated mental disorders; or have a combination of these problems. The Minnesota Health Professional Services Program (HPSP) (www.hpsp.state.mn.us) provides monitoring for physicians who are seeking treatment for chemical dependency or mental health issues.(8) The HPSP monitors physicians and other licensees who have such diagnoses and are engaged in therapy or rehabilitation. Their treating physicians and other professionals submit periodic reports to HPSP, which report on a physician’s progress or compliance to the BMP.

A small number of sociopathic doctors sexually exploit patients simply because they believe they can get away with this behavior. These doctors are unlikely to pursue meaningful psychotherapy; and they may or may not tolerate being monitored by the BMP. Most offending physicians, however, realize that they have made poor choices and regret them. Carr contrasts the characteristics of physicians who can achieve rehabilitation with those who cannot. Among the disease and physician characteristics that Carr considers to be indicators of a positive prognosis for physicians who have committed sexual boundary violations are: having a substance-related disorder diagnosis, being able to be honest, being motivated/compliant, showing remorse, showing empathy for the victim (in this case, the former patient), insightfulness, having a recovery and peer support system in place, having an ongoing positive relationships with family and significant others, having recent identifiable psycho-social stressors, and having treatable mental disorders.(6) Bad prognosticators include: acting out despite sanctions or when under monitoring, refusing to end a sexual relationship, being profoundly self absorbed (narcissistic), being very dependent on the approval of others, refusing to allow or accept advice and support from peers and family, having pervasive boundary violations, and showing strong antisocial traits.

For most physicians, the ultimate goal of their treatment is rehabilitation and return to medical practice. To achieve this, they must be able to sustain safe and healthy doctor-patient relationships. Based on our experiences working with impaired physicians, we agree with Carr that most physicians who have committed a sexual boundary violation can be rehabilitated so that they can return to practice.(6) This may require different practice settings or degree of supervision. In some cases, career change may be necessary. For physicians in psychotherapy, treatment goals and strategies include an understanding of factors leading to doctor-patient boundary violations and rehearsing scenarios for alternative behaviors. Thus, part of the psychotherapy is an ongoing analysis of the physician’s skill and comfort maintaining appropriate professional boundaries with patients.

Nonetheless, the priority of the medical board is to protect the public from exploitative doctors. For that reason, the psychiatrist, counselor, or therapist working with a physician who has crossed boundaries should not offer guarantees of confidentiality if the problem behavior reoccurs. In this sense, the therapy model for treating these physicians is similar to that of military psychiatrists or occupational physicians who examine patients for work readiness and report to the employer if the subject is unfit for duty. This obligation can pose a conflict for the psychiatrist or therapist unless the treating doctor and the patient are each committed to the primary goal of public protection.

Summary

Physicians who cross sexual boundaries with patients place themselves in great peril. They risk tainting or destroying their professional reputations; damaging their health; and losing their jobs, contracts with payers, and hospital privileges. They jeopardize their financial security, bring shame to and conflict within their families, and may lose their license to practice medicine. Public awareness about the problem of sexual boundary violations by professionals is growing, as is disdain for all persons in fiduciary roles who engage in sex with those for whom they are responsible and over which they have power, whether they be wards, patients, or parishioners. The clergy scandals in the Catholic church highlight this growing public intolerance. Sexual misconduct is a serious black mark on a physician’s career. However, some physicians who demonstrate remorse, undergo therapy, and are willing to work with the Board of Medical Practice to regain the public trust can reclaim their careers.

The opinions expressed in this article are the author’s and do not represent positions of the Board Medical Practice or any other state agency.

Acknowledgement

The authors wish to thank Christina Rich, J.D., legal counsel for the Minnesota Medical Association, and Monica Feider, M.S.W., LICSW, HPSP Program Manager for their help in preparing this article.

Lee H. Beecher, M.D. is a psychiatrist in private practice in St. Louis Park, president of the Minnesota Physician-Patient Alliance, and a clinical associate professor of psychiatry at the University of Minnesota. Steven I. Altchuler, M.D., Ph. D. is co-chair of the Division of Tertiary Psychiatry and Psychology at Mayo Clinic in Rochester, MN, and serves as vice president of the Minnesota Board of Medical Practice.

Footnotes

Gartrell ND, Milliken N, Goodson WH, Thiemann S, Physician-patient sexual contact: prevalence and problems. West J Med 1992;157:139-143.
Simon RI. Therapist-patient sex. From boundary violations to sexual misconduct. Psychiatr Clin North Am. 1999;22:31-47.
Minnesota Board of Medical Practice. Report to the Minnesota Medical Association House of Delegates, September 2004
Beecher LH. Doctor-patient boundaries: road rules and red flags. Minn Healthcare News. 2005l3(2):28-30.
Carr GD. Professional sexual misconduct—an overview. J Miss State Med Assoc. 2003;44(9):283-300.5.
Minnesota Statutes, Chapter 147. Physician Practice Act.
Gutheil TG, Gabbard GO. Obstacles to the dynamic understanding of therapist-patient sexual relations. Am J Psychother. 1992;46(4):515-25 (1992).
Roberts K, Specker S. The health professional services program: an alternative for physicians with psychiatric disorders. Minn Med. 1999;82(10):54-6.