A Continuing Education Course For Physicians Who Cross Sexual Boundaries

A CONTINUING EDUCATION COURSE FOR PHYSICIANS WHO CROSS SEXUAL BOUNDARIES
Anderson Spickard, Jr., M.D., William H. Swiggart, M.S., Ginger Manley, M.S.N., R.N., C.N.S., David Dodd, M.D.The Center for Professional HealthVanderbilt University School of Medicine
Professional sexual boundary violations are the subject of major interest in professional and lay literature, calling attention to the special hazard of sexual relationships between persons in positions of authority over others. (Guthiel, 1993; Irons and Schneider, 1994; Overlock, 1996; Rutter, 1998, 1999; Morris, 1999). These publications emphasize the special risks to physicians who cross sexual boundaries with patients and staff and cause serious risk management issues for themselves and their practice. Long before the current publicity about this subject the problem of physicians violating professional boundaries was addressed in the report of the Council on Ethical and Judicial Affairs of the American Medical Association in 1991(AMA 1991). These ethical standards state that: 1) sexual contact or a romantic relationship concurrent with the physician-patient relationship is unethical, 2) sexual contact or a romantic relationship with a former patient may be unethical under certain circumstances, 3) education on the ethical issues involved in sexual misconduct should be included throughout all levels of medical training and 4) in the case of sexual misconduct, reporting of offending colleagues is especially important. Winn has described the increase in incidence of problems of boundary violations as seen by the state medical boards. (Winn, 1993)
Gabbard and Nadelson in a special communication in the JAMA summarized the professional boundaries in the physician-patient relationship. (Gabbard, 1995) Dual relationships, gifts and services, time and duration of appointments, language, self-disclosure, the physical examination, physical contact and prevention of boundary violations were noted.
Schneider and Irons define the various categories of sexual boundary violations in their textbook for clinicians and counselors who specialize in evaluation of physicians with suspected sexual addiction. (Irons, Schneider, 1999) In addition, Irons has reviewed the recognition and management of the seductive patient, encountered frequently by all physicians. (Irons, 1994)
The Report on Sexual Boundary Issues by the Ad Hoc Committee on Physician Impairment of the Federation of State Medical Boards of the US, Inc. (FSMB) outlines the current concepts regarding physician impairment in sexual boundary issues and recommends guidelines for state medical boards that are investigating sexual misconduct in physicians. (Ad Hoc Committee, 1994). The FSMB recommends that state medical boards provide both interventions for physicians who cross sexual boundaries with patients or staff in their practice. Interventions include continuing education, in-depth assessment for sexual addiction, and careful monitoring of the physician's behavior to prevent recurrence of these boundary violations.
Physician education is the cornerstone of prevention of sexual boundary violations by physicians. The Federation report emphasizes that physician sexual misconduct has not been adequately addressed during medical school or residency training and that medical boards should take a proactive stance to educate their licensees about sexual misconduct. Because of this lack of education/awareness, physicians encounter situations in which they have unknowingly violated the medical practice act through boundary violations. The Committee urges improvement in education of physicians about acceptable and unacceptable behavior in regard to sexual boundary issues, with emphasis on the serious emotional harm patients can experience when sexual boundary violations occur. They challenged medical boards to publish information in newsletters and contact media to inform the public.
In response to these observations and recommendations, a continuing medical education course entitled 'Maintaining Proper Boundaries- A CME Course for Physicians' has been conducted at Vanderbilt Medical Center for the past two years. The initial courses were supported by a grant from the American Foundation for Addiction Research (AFAR), a foundation devoted to education and research on sexual abuse and addiction. This report describes the experiences with training thirty physicians who have been mandated from their state medical board, physician health program or are self referred.
COURSE DESCRIPTION
This three-day course was begun in July 1999 in the Center for Professional Health at Vanderbilt University Medical Center in Nashville, Tennessee. Three recovering physicians who had already been involved in the Tennessee Physicians Health Program because of their sexual boundary issues reviewed the proposed program.
The faculty is composed of two physicians, a nurse specialist and an addiction counselor. All are trained in addiction and are acquainted with the particular defenses of minimizing, rationalizing, and denying in addicts of all kinds. The course faculty members had experience in teaching physicians referred by state medical boards or physician health programs, having conducted a previous course for physicians who misprescribed controlled substances, principally Schedule II narcotics. (Spickard, 1998, 1999; Swiggart, 1998) Over 300 physicians have attended this course in the 15 years of existence. A few of these physicians had become involved in sexual boundary violations associated with the prescribing of narcotics to their lovers, but sexual boundary violations were not being addressed in any depth in those courses.
The earlier experience had shown that in a three-day format which combined didactic material with guided introspection, a majority of those physicians were able to not only be honest about their prescribing boundary issues, but they also could begin to access deeply held emotions which had previously not been accessible. In the safe setting of other colleagues and with an empathetic faculty, the attendees took ownership of their own failings and were able to receive guidance in reorganizing their professional and personal lives. Using that experience, and with the consultation of well-known experts in physician sexual boundary concerns, a new three-day course format, based on the earlier prescribing course, was developed.
The course is limited to 10 participants in each offering. Physicians who complete the course receive 21 CME credits and a certificate of attendance. All of the discussions occur under a code of strict confidence. Medical boards receive letters indicating only that the physician had completed the course. Letters to lawyers and others if required have been sent only with the physician's written permission.
The course content contains sections on:
* Psychology of the physician;
* General and sexually specific boundary definitions;
* Power imbalances in practice;
* Progression of behaviors model including use-misuse-compulsion-addiction continuum;
* Shame/guilt development and styles of coping;
* Family of origin genograms, with special emphasis on the 'grooming' and socialization of the physician-to-be in his/her family of origin;
* Collateral addictions and recovery programs;
* Guidelines for safety in professional practice;
* Victim empathy
* Intent to change statements.
Each participant receives a course syllabus upon registration, and the course content is preprinted in the syllabus so that they can absorb the material without the need to take extensive notes. In addition numerous reference articles are included in the bibliography to supplement the course materials.
Didactic presentations are offered in a classroom setting. The participants are given approximately two hours of homework each night of the course, during which time they complete their personal genogram and complete a battery of self-report questionnaires. Group processing takes place when the participants are divided in to two small groups facilitated by two faculty members in each group. The participants discuss their genograms and questionnaires on the second and third days in these groups.
In another session the wife of a recovering sexually addicted physician, not in the course, provides a moving story of her experiences of coping with the addictive behavior of her husband. The physicians attending the course listen to her experience and interact with her during a period afterwards, facilitating the personalization of her experience for the attendees.
SCREENING INSTRUMENTS
There was concern by the course faculty that the CME course would provide just education for sexual boundary offenders who were unrecognized sexual addicts and who actually needed more in depth assessment and treatment. Some of the participants have self-reported themselves to be sexual addicts who had previously attended treatment centers for sexual addiction. Their attendance at the CME course was a condition of the court order or prior to reentry to practice as part of their treatment contract with the treatment center. The faculty was concerned about the possibility that the course per se might not be sufficient to rule out more serious problems, having observed in the previous misprescribing course the frequency of dysfunctional family of origin issues and the occurrences of other addictions in the family histories.
Two self-report instruments, the SAST (Carnes, 1989) and the FACES II (Olson, 1993) were used. The SAST [sexual addiction-screening test) differentiates sexual addicts from non-addicts based on a cutoff score of 13 positive answers out of 25 possibilities. Results of the SAST given to the physicians in the courses show that the majority of physicians (23 or 77%) scored under the cutoff score of 13 while 7 (23%) were above the cutoff indicating that most of the physicians attending the course are not addicted. The seven who were screened as possibility having sexual addiction were counseled to seek additional in-depth assessment for possible sexual addiction.
The FACES II, developed by Olson and colleagues (Olson, 1993), is a measure of family function on two dimensions, flexibility and cohesion. The physician participants are asked to answer the questions about their family of origin. The results place the family in one of three categories, 'balanced' (healthy), 'midrange' (between healthy and extreme) and 'extreme' (unhealthy). (Table 1) The majority of scores indicated that the families of these physicians were in the 'midrange' category as defined by this test. Four of the seven with high SAST scores were also in the extreme range.
PARTICIPANTS
Thirty-eight physicians attended the CME course during 1999-2000 for which we have information. Eight physicians refused to have their information included in the data set. The summary of the demographics for the group of 30 who consented to be included is in Table 2. The specialties represented by these physicians are listed in Table 3.
Case Study
The following case study describes a typical physician's history and is a combination of several physician stories to obscure identification. Dr. Smith is a 42-year-old male internist. He practices in an office with three other physicians in a small town in the mid-west. He has been divorced for six years and has no children. He works long hours to forget the loneliness and his feelings about the divorce. Many of the single women available in his community for him to date were also his patients, so his choices for a companion were limited. He became attracted to a female technician who worked in the hospital to which he admitted patients and their relationship turned into a sexual involvement.
During the course of their relationship his companion mentioned a need for pain relief for chronic back pain unresponsive to the usual non-narcotic treatments for pain. She was dissatisfied with her own doctor's care and believed he was under-treating her pain. Dr. S was reluctant to prescribe for her, but he finally relented and began giving her regular prescriptions for Tylenol/hydrocodone.
One year later Dr. Smith decided to end both the sexual relationship and his treatment of his companion's pain. She was not only disappointed that the sexual relationship was over but was angry that he would not prescribe for her pain. She reported Dr. Smith to the state board of medical examiners. The board concluded that Dr. Smith had crossed two boundaries. His personal relationship with a hospital employee was inappropriate because he had supervisory responsibilities in the department where his lover worked, and he had prescribed controlled substances for her pain without a medical record.
Dr. S. was mandated to attend the course on sexual boundary violations. He arrived with an angry, hostile, and defensive attitude. The first day of the course he began to hear other physicians' experiences, and realized that his troubles were not as serious as some. He realized how his medical training that emphasized his role of controlling situations and ignorance of the overlap with the vulnerability he brought to his medical practice from his own family origins might have conspired to cause problems. He completed the course feeling supported in his attempt to be a better physician, and with clear plan to avoid similar problems. The BME in his state concluded he had engaged in sexual impropriety but was not addicted or predatory and allowed him to return to practice without further sanctions.
Discussion
All physicians initially have a high level of anxiety and anger at the beginning of the course. Many physicians do not know the details of the violations for which they have been reported. If there is no lawyer representing them, the specifics of the complaints can be very unclear. Some physicians have been told to go to a CME course on sexual boundary violations and all will be forgotten. We have been impressed with the different approaches state boards have on this issue, some being very strict and punitive and others emphasizing more of a rehabilitative approach.
This CME course is substantially different from the typical CME courses familiar to most of the attendees where didactic presentations of the course material are the usual method of teaching. The format used in the Vanderbilt course of sharing of personal stories in a confidential setting with faculty who do a limited amount of their own self-disclosure quickly breaks down barriers. Some participants are fairly far along in their own recovery when they attend the course, while others have only a vague notion of the scope of their problems. Regardless of the status of their own self-identification, the group members become cohesive and supportive of each other. They confront one another when appropriate, and they encourage and give support to their peers when indicated. By the end of the course, almost all participants have stated that they believe that the course has been very important to their well being personally and professionally.
There are inherent limitations to this educational intervention. Primarily this format does not provide an in-depth assessment of each physician to determine his or her level of sexual behavior, i.e. to separate the abuser from the addict. The faculty cannot be certain about the level of sexual impropriety or violation as defined by the FSMB reports (Ad Hoc Committee on Physician Impairment, 1994). With the informal group process, the use of the SAST, FACES and genogram review, the faculty members do, however, have a good sense of who is addicted and needs more in-depth assessment and treatment.
There is no doubt the group process used in this course for physicians is very important as a therapeutic intervention. Though initially angry and frustrated about being sent to the course, with time and sharing their stories, the participants relax, tell stories, laugh at themselves and each other and become bonded as a group in a short time. Their stories bear out the fact that physicians are starved for relationships with peers. We have been impressed with the openness and honesty in this group of physicians. The commitment of confidentiality by all participants and the faculty is a factor in promoting honesty. Since the CME course is only an educational program, none of the material on any physician is discoverable. This contributes to the honesty we have experienced in working with these individuals.
All the physicians in this course were uninformed and poorly trained in medical school or residency about sexual boundary issues. They were unaware of guidelines and policies of state and national groups about these matters. They did not have policies in their practice to recognize non-sexual and sexual boundaries. Sexual harassment policies are unknown to them even though such policies are federal laws. Neither newsletters from their liability insurance carriers nor or correspondence by their state medical board have informed any of the participants. As a group they report being astounded when angry patients file complaints.
Physicians usually do not realize that the role of the state medical board is to protect the public as their primary mission. In most cases the physician health program in their state is available to advocate for their interests and testify before the board in their behalf when appropriate. However, sexual boundary violation issues are only recently in the spotlight of medical board deliberations and leaders of physician health programs and board members may be untrained and uninformed about the issues.
Physicians report having had some training in recognition of and treatment of the seductive patient, but the issues of transference and counter transference in the patient encounter seem to be remote principles mentioned only in a psychiatry course in medical school. The physicians we see have no idea how these principles apply to them or the physician/patient encounter. The emotionally vulnerable patient as a prelude to a sexual affair with their patient has never been mentioned to them as a red flag in practice. Physicians have not been taught about their own emotional vulnerability to sexual encounters with patients or staff when they are tired or have family difficulties.
Most physicians are competent in cognitive medical principles, but have difficulty expressing emotion or displaying feelings appropriately. Often physicians do not realize that their failure to deal with feelings will make them vulnerable to an emotionally needy patient or staff member. In these relationships the power differential of the physician/patient relationship in not realized by the physician and the physician proceeds with a conquest unaware that he is liable in this affair and that the female patient or staff member is probably not going to be held culpable. Some physicians have tried to cover this situation with agreements with the patient or staff member before the sexual encounter takes place. In each case this has backfired upon him. One physician said after having an affair with a patient, 'She agreed to one $40 one night stand in the motel and my practice and family is ruined.'
We have also been impressed with the lack of understanding about non- sexual boundaries that are crossed in many physician practices. Some practices in small hospitals and even specialty units in large hospitals are operating more like TV style MASH units than like professional practices. The informality of dress, language, personal interactions between the sexes create and atmosphere in which sexual boundary violations are likely to occur. Professional distance and doctor/nurse roles are blurred in an atmosphere where dress codes are not enforced and everyone is called by their first name. Physicians see patients outside office hours and without a chart, prescribe for staff in the hallway, accept large gifts from patients, engage in business deals with patients and form dual relationships that easily escalate into sexual boundary affairs.
Office procedures without proper chaperones are a common problem. Some physicians use family members as chaperones (especially in pediatric cases), fail to drape patients properly and treat the female patient in an unprofessional manner (commenting on her pretty underwear, anatomy, etc.) Constant flirting is a common reason physicians are referred to the course. Telling off color jokes and/or having inappropriate pinups on the office desks are common complaints by employees.
We have been impressed by the physician's inability to say 'no' to patients and staff members even if one's license to practice can be jeopardized. Prescribing narcotics to a sexual partner who is a patient or staff member is not uncommon. In one year of the misprescribing course, nine of forty physicians were involved in this dual boundary violation.
During the course we have been impressed by the physicians' responses to the victim empathy lecture and the story of a wife of a serious sexual addict who had been in treatment for his addiction. Many of our physicians experienced fractured relationships with their wives and hearing a story from an emotionally devastated wife was a powerful message.
Our experiences with some physicians from other cultures who are practicing in various specialties in the U.S. demonstrate a significant lack of understanding about American social and sexual mores. Physicians from India, South America and the Middle East have made many mistakes of language, touching, etc. that are uncomfortable to the American female and lead to reports of sexual boundary violations. Education of international physicians about these issues is a high priority.
SUMMARY AND RECOMMENDATIONS
* All medical schools, residency training programs, state medical boards and other physician education training groups should provide training for physicians in prevention of sexual boundary misconduct.
* Medical school curricula should provide training in feelings for physicians to assist them an understanding of their own feelings and those of their patients.
* There should be organized support groups for physicians to assist them in processing feelings about difficult patients, family crises, practice crises, etc. The effectiveness of support groups for residents and practicing physicians has been documented.
* Programs assessing physicians cited for sexual boundary violations should consider genograms, SAST and the FACES screening tests to uncover unsuspected sexual addiction and serious family of origin issues affecting the physician's behavior.
* All physicians' offices should display the AMA code of ethics or the appropriate specialty's ethical policies guiding the physician's behavior and that of the office staff. Patients will be reassured if there is visible evidence that the physician leader of the practice and the staff commit to ethical behavior and high standards of patient care.
REFERENCES
Ad Hoc Committee on Physician Impairment (1994). Report of the federation's ad hoc committee on physician impairment. Federal Bulletin: 81, 229-242.
American Medical Association - Council on Ethical and Judicial Affairs (1991). Sexual misconduct in the practice of medicine. Journal of the American Medical Association. 266, 2741-2745.
Bloom, J.D., Nadelson, C.C. & Notman, T.N. (Eds.) (1999) Physician sexual misconduct. American Psychiatric Press, Washington, D.C.
Carnes, P. (1989) Contrary to love. Hazelden, Center City, MN.
Gabbard, G., & Nadelson, C. (1995). Professional boundaries in the physician-patient relationship. Journal of the American Medical Association. 273 (18). 1445-1449.
Gutheil, T.G., & Gabbard, G.O. (1993). The concept of boundaries in clinical practice: theoretical and risk-management dimensions. American Journal of Psychiatry. 150. (2). 188-196.
Irons, R. (1994). On seduction and exploitation: a medical model approach. Rhode Island Medicine. (77). 354-356.
Irons, R.R., & Schneider, J.P. (1994). Sexual addictions: significant factor in sexual exploitation by health care professionals. Sexual Addiction and Compulsivity. 1. (3), 198-214.
Irons, R.R., & Schneider, J.P. (1999). The wounded healer: addiction-sensitive approach to the sexually exploitative professional. Northvale, NJ: Jason Aronson Publishers.
Morris, B. (1999, May 10). Corporate America's dirty secret: addicted to sex. Fortune. 69-80.
Olson, D.H. (1993). Circumplex model of marital systems: assessing family functions. Normal Family Processes. Welsh, F. (ed). Chapter 3, 104-137.
Overlock, M., & Gonzales, R. (November 1996). Crossing a patient's sexual boundaries. Tennessee Medicine, 403-404.
Rutter, P. (1991). Sex in the forbidden zone. Toronto, Canada: Ballentine Books.
Spickard, A., Dodd, D., Dixon, G., Pichert, J., & Swiggart, W. (1999). Prescribing controlled substances in Tennessee: progress, not perfection. Southern Medical Journal. 92. (1). 51-54.
Spickard, A., Dodd, D., Swiggart, W., Dixon, G., & Pichert, J. (1998). Physicians who misprescribe controlled substances: a CME alternative to sanctions. Federation Bulletin. 85. (1). 8-19.
Swiggart, W., Pichert, J., Elasy, T., Dixon, G., & Spickard, A. (1999). Continuing medical education courses on proper prescribing of controlled substances in the United States. Federation Bulletin. 86. (1). 20-27.
Winn, J.R. (Summer 1993). Medical boards and sexual misconduct: an overview of federation data. Federation Bulletin. 90-97.
Physicians and Sexual Boundary Violations