Advice to the Profession: Maintaining Appropriate Boundaries

Advice to the Profession companion documents are intended to provide physicians with additional information and general advice in order to support their understanding and implementation of the expectations set out in policies. They may also identify some additional best practices regarding specific practice issues.

Background

There is an inherent power imbalance within the physician-patient relationship which is a result of a number of factors:

A patient depends on the physician’s knowledge and training to help them with their health issues.
A patient shares highly personal information with the physician that they rarely share with others.
The clinical situation often requires that the physician conduct physical examinations that are of a sensitive nature.
A patient’s vulnerability is heightened when they are unwell, worried or undressed.

As such, a physician must only act in the patient’s best interests and must take responsibility for establishing and maintaining boundaries within a physician-patient relationship.

If physicians do not do this, individual patients may be harmed and the public’s trust in the medical profession may be eroded.

Frequently Asked Questions about Sexual Boundary Violations

What are the consequences to physicians for sexually abusing a patient?

Physician Conduct	Penalty	Reapplication
Sexual intercourse with a patient.	Revocation of certificate of registration	No earlier than 5 years from date of revocation
Genital to genital, genital to anal, oral to genital, or oral to anal contact.	Revocation of certificate of registration	No earlier than 5 years from date of revocation
Masturbation of a physician by, or in the presence of, the patient; masturbation of the patient by a physician; encouraging the patient to masturbate in the presence of a physician.	Revocation of certificate of registration	No earlier than 5 years from date of revocation
Touching of a sexual nature of the patient’s genitals, anus, breast or buttocks.	Revocation of certificate of registration	No earlier than 5 years from date of revocation
All other instances of sexual abuse e.g., behaviour or remarks of a sexual nature by a physician towards their patient.	The Discipline Committee is required to, at a minimum, reprimand the physician and order a suspension of their certificate of registration. In these instances, the Committee has the power to order revocation of the physician’s certificate, although such revocation is not mandatory.	No earlier than 5 years from date of revocation
Physician has been found guilty of professional misconduct by the governing body of another health profession in Ontario, or by the governing body of a health profession in a jurisdiction other than Ontario and the misconduct includes or consists of the specific acts of sexual abuse described above.	Revocation of certificate of registration	No earlier than one year from date of revocation
Physician has been found guilty of an offence that is relevant to the member’s suitability to practise and the offence is prescribed in a regulation made under clause 43 (1) (v) of the Regulated Health Professions Act, 1991.	Revocation of certificate of registration	No earlier than one year from date of revocation

What if my patient agrees to a sexual relationship?

Under the RHPA sexual contact with a patient is considered sexual abuse even if a patient has agreed to a sexual relationship. This is because of the power imbalance inherent in the physician-patient relationship.

What do I do in situations of uninitiated patient contact?

If a patient initiates inappropriate contact with you, for example, repeated personal emails or texts, you will need to re-establish the professional boundary between you and your patient. It is good practice to document the uninitiated interaction or contact and how you responded to it in the patient’s medical record. If the patient’s behaviour persists, it may be appropriate to terminate the physician-patient relationship in accordance with the College’s Ending the Physician-Patient Relationship policy.

What is the difference between a boundary crossing and a boundary violation?

Boundary violations occur when a physician does not establish and/or maintain the limits of a professional relationship with a patient. The Boundary Violations policy sets out firm expectations for physicians to comply with in order to ensure that boundaries are not violated. Boundary violations occur when these expectations are not complied with. Such violations are exploitative.

Boundary crossings are different than violations in that they are minor deviations from traditional therapeutic activity that are non-exploitative and are often undertaken to enhance the clinical encounter. For example, accepting a small gift from a patient or holding of the hand of a grieving patient. While these actions may be well-intentioned, it is important for physicians to consider what these actions can mean to patients and their impact on the physician-patient relationship or on other patients in their practice. Repeated boundary crossings may often lead to a boundary violation.

Communication with Patients

How do I obtain consent before examining my patient?

Prior to examining your patient, explain what you will be doing and why in a concise and easily understood manner. Then you can ask, “is this okay?”. Getting consent from your patient for an examination should not be burdensome or time-consuming and will ensure your patient knows what to expect during their appointment with you.

How can I incorporate trauma-informed care into my practice?

Trauma-informed care is defined as practices that promote a culture of safety, empowerment, and healing. A medical office or hospital can be a difficult experience for someone who has experienced trauma, particularly for childhood sexual abuse survivors. It is important to recognize how common trauma is and to understand that any patient may have experienced serious trauma. Physicians can assume that a patient may have this history and act accordingly. For example, explaining why the exam needs to be performed, telling patients that if they need a physician to stop the exam, that they can tell them so and letting patients bring a trusted friend or family member into the examination room with them.

Can I use touch for comforting purposes?

The policy states a physician must use their professional judgment to determine when to use touch for comforting purposes. In using their professional judgment, there are a number of factors that physicians can consider including, how long the individual has been their patient, that the patient may have experienced trauma, and why the patient may need comforting touch. A physician may also want to consider asking a patient if it is okay to hug them or touch them in a comforting manner. These steps align with the provision of trauma-informed care.

Can I communicate with my patients on Social Media?

Physicians are expected to comply with all of their existing professional expectations, including those set out in relevant legislation, codes of ethics, and College policies, when engaging in the use of social media platforms and technologies.

As set out in the policy, making comments of a sexual nature towards a patient is considered sexual abuse under the RHPA and this would apply equally to comments of a sexual nature made to a patient on social media.

In communicating to my patients, can I disclose information about myself?

Self-disclosure can be a challenging area to navigate. It is important for physicians to use their professional judgment when disclosing personal information to patients, considering factors such as the nature of the information being disclosed, the length and nature of the physician-patient relationship, and the purpose of self-disclosure.

Third Parties at Examinations

The Boundary Violations policy outlines what the College expects of a physician who is not able to provide a third party for their patient when conducting an intimate examination.

A physician may want to consider informing patients (through their administrative staff or themselves) when booking appointments that they are not able to offer a third party, but if the patient would like to have a third party present they may bring their own third party, e.g., a family member or a friend to the appointment. Having a sign posted in a physician’s office about third-party attendance at intimate examinations does not satisfy the requirement.

What if I am not able to provide a third party for my patient?

In limited clinical settings, such as an emergency department, an intimate examination may not be as foreseeable as it would in a different setting (e.g., a scheduled pelvic examination) and it may be more difficult to find an available third party. In these circumstances, where the patient does not have an available third party who has accompanied them, a physician could explain to the patient that a third party may be obtained but it could take some time for this to happen. If the examination is not urgent, the patient can then decide whether they want to wait until the third party can attend.

What should I document in relation to third parties?

When a third party is declined by a patient, it may be worthwhile for physicians to document the decision in the patient’s medical record.

If a third party is present, physicians may want to document whether the third party has been provided by the physician or the patient.

Privacy

How can I provide privacy for my patients?

As stated in the Boundary Violations policy, physicians must provide privacy when a patient undresses and dresses. This can be achieved by having an appropriate place for a patient to undress and dress out of view of anyone, including the physician, e.g., a separate examination room where a patient can change or having a suitable curtain between the physician and the patient. Merely turning around and facing away from a patient without a curtain is not acceptable.

Sexual Relationships with Former Patients and Others Close to Patients

Why might it not be appropriate and/or professional misconduct for a physician to have sexual relations with a patient even after the physician-patient relationship has ended?

At all times, a physician has an ethical obligation not to exploit the trust, knowledge and dependence that develops during the physician-patient relationship for the physician’s personal advantage. This dependence does not disappear once the physician-patient relationship has ended — the power imbalance can persist after a person ceases to be a physician’s patient.

As such, for the purposes of sexual abuse, the RHPA treats the physician-patient relationship as continuing one year past the last physician-patient encounter.

Prior to engaging in sexual contact, physicians are advised to verify that they have not provided treatment to the individual within the prior year. Even after this time period has elapsed, sexual relations may be considered professional misconduct. In addition, the Courts have found that certain physician-patient relationships may endure subsequent to the end of the formal relationship, for example, in the case of a long-standing psychotherapeutic relationship. Depending on the nature and extent of the psychotherapeutic relationship, it may never be appropriate to have a sexual relationship with a former patient.

A physician who is considering having sexual relations with a former patient must use their professional judgment, acting cautiously as they consider the potentially complex issues relating to trust, power dynamics and any transference concerns. As well, it is important for a physician to explain to a former patient the dynamics of a physician-patient relationship and the boundaries applicable to that relationship.

Where a physician is in doubt as to whether the physician-patient relationship has ended, they should refrain from any relationship with the patient until they seek advice, for example, from legal counsel.

Why might it not be appropriate for a physician have a sexual relationship with a person closely associated with a patient?

Sexual relations between physicians and individuals who are closely associated with a physician’s patients may also raise concerns about breach of trust and power imbalance, and may be considered professional misconduct.

In addition to the risk of exploitation, sexual relations between a physician and a person closely associated with a patient can detract from the goal of furthering the patient’s best interests. It has the potential of affecting the physician’s objectivity and the closely associated person’s decisions with respect to the health care provided to the patient.

Mandatory Reporting

What does ‘reasonable grounds’ mean in the expectation for physicians to report sexual abuse?

Courts have described the test as a “reasonable probability” or a “reasonable belief”. This is a low threshold; however, it is a higher threshold than a mere suspicion and a lower threshold than proof on a balance of probabilities.

For example, in most circumstances, where a patient tells you that they have experienced sexual abuse by another physician, this would need to be reported to the College. Additional corroborative evidence is not required and you should not attempt to investigate the patient’s allegations.

Frequently Asked Questions about Non-Sexual Boundary Violations

How do non-sexual boundary violations impact the physician-patient relationship?

Non-sexual boundary violations can occur when a physician has a social relationship and/or a financial/business relationship with a patient.

It is important for physicians to be aware of the increased risk associated with managing a dual relationship with a patient, including the potential for compromised professional judgment and/or unreasonable patient expectations. The following activities may have the potential to cause harm particularly when the physician uses the knowledge and trust gained from the physician-patient relationship.

Social relationships can include the following activities:

Giving or receiving inappropriate or elaborate gifts;
Asking patients directly, or searching other sources, for private information that has no relevance to the clinical issue;
Asking patients to join faith communities or personal causes; or
Engaging in leisure activities with a patient.

Financial/business relationships can include the following activities:

Lending to/borrowing money from patients,
Entering into a business relationship with a patient, or
Soliciting patients to make donations to charities or political parties.

What should I do when my patients are part of my social network?

The College does not prohibit physicians and patients from interacting within the same social network. In fact, we recognize that this is a reality of practice for many physicians. For example, in small communities and in religious, language and ethnic communities, physicians will be invited to, or engaged in, social events and activities with patients.

We understand that these issues can be challenging for physicians; however, as set out in the answer above, physicians need to manage the increased risks associated with having a dual relationship with a patient. For example, it is best practice for professional issues to be discussed in the physician’s office.

The College’s Physician Treatment of Self, Family Members, or Others Close to Them policy also contains important information with respect to this issue.

Resources

The information below provides additional guidance for physicians with respect to maintaining appropriate boundaries and avoiding sexual abuse complaints.

Dialogue Articles

Dialogue, the College’s quarterly publication for members, regularly addresses themes or issues relating to boundary violations, including sexual abuse. While some expectations may have changed since these articles were published, they contain helpful advice. Some examples are linked below:

Discipline Committee Findings

Past findings of the College’s Discipline Committee can also be instructive as to what behaviours have resulted in findings of sexual abuse and/or disgraceful, dishonourable or unprofessional conduct.

The lists below are not exhaustive and the Discipline Committee would examine the facts of a specific case to see whether the conduct amounts sexual abuse or disgraceful, dishonourable or unprofessional conduct.

The Discipline Committee has made findings of sexual abuse in situations which include the following conduct:

Remarks of a sexual nature to a patient including comments sexualizing the patient’s appearance where there is no therapeutic value in the remarks,
Stroking a patient’s buttocks as they were leaving an appointment,
Sexual touching while the patient was under anesthetic, and
Kissing a patient.

Additionally, the Discipline Committee has determined that the following types of behaviour amounted to disgraceful, dishonourable or unprofessional conduct.

Borrowing money from a patient;
When providing counselling: hugging and providing a kiss on the cheek, meeting outside of the office on three occasions including at a restaurant;
Failing to provide adequate explanation and obtaining informed consent prior to and during a sensitive examination
Failing to provide adequate coverage for an examination resulting in unwanted exposure;
Repeated, unwanted touching of nursing colleagues; and
Engaging in a sexual relationship with a patient too soon after the termination of the doctor-patient relationship.

Canadian Medical Protective Association

The CMPA is a national organization and provides broad advice about a number of medico-legal issues. For Ontario specific information physicians are advised to look at the CPSO policy and advice document regarding boundary issues. However, the CMPA has a number of resources on the issues generally that physicians may find helpful.

For example: