The doctor-patient relationship is an intimate relationship. It is based on trust. One of the tenets of trust is that it will not be exploited for personal gain.
Doctors become aware of patients’ most private secrets. And their vulnerabilities.
Still, medicine is “hands-on.” Examination of the patient often requires touch. And, if a patient initiates touch, such as a hug, what’s a doctor to do?
Reciprocate?
Back off?
Well, it probably depends.
It depends upon context. The potential cultural background of the patient and their expectations. And more.
To me, medicine would be a particularly sterile endeavor if it were 100% devoid of touch. Touch is how we convey warmth and empathy.
Of course, touch can be misinterpreted.
So, caution is in order.
To understand why caution is in order, I turn to a document, adopted as policy by the Federation of State Medical Boards (FSMB) in May 2020, “Physician Sexual Misconduct.” The FSMB is the umbrella organization for the various state medical and osteopathic boards. Each state board adopts its own rules and regulations. But FSMB is very influential. This document is over 30 pages long. I excerpted some of the salient paragraphs.
For the purposes of this report, physician sexual misconduct is understood as behavior that exploits the physician-patient relationship in a sexual way. Sexual behavior between a physician and a patient is never diagnostic or therapeutic. This behavior may be verbal or physical, can occur in person or virtually, and may include expressions of thoughts and feelings or gestures that are of a sexual nature or that a patient or surrogate may reasonably construe as sexual. Hereinafter, the term “patient” includes the patient and/or patient surrogate.
Surrogates are those individuals closely involved in patients’ medical decision-making and care and include spouses or partners, parents, guardians, and/or other individuals involved in the care of and/or decision-making for the patient.
Note, sexual misconduct does not have to be physical. It could be a text message. A phone call. It doesn’t have to be confined to a patient. It could be the mom of a pediatric patient, for example – a decision maker for the actual patient. Importantly, there may be a wide gulf between what was intended and what was perceived. In the eyes of the FSMB, what “happened” will be reviewed through the lens of the patient. “This behavior [is one that] may reasonably [be] construe[d] as sexual.”
Physician sexual misconduct often takes place along a continuum of escalating severity. This continuum comprises a variety of behaviors, sometimes beginning with “grooming” behaviors which may not necessarily constitute misconduct on their own, but are precursors to other, more severe violations. Grooming behaviors may include gift-giving, special treatment, sharing of personal information or other acts or expressions that are meant to gain a patient’s trust and acquiescence to subsequent abuse.
More severe forms of misconduct include sexually inappropriate or improper gestures or language that are seductive, sexually suggestive, disrespectful of patient privacy, or sexually demeaning to a patient. These may not necessarily involve physical contact, but can have the effect of embarrassing, shaming, humiliating or demeaning the patient. Instances of such sexual impropriety can take place in person, online, by mail, by phone, and through texting.
The severity of sexual misconduct increases when physical contact takes place between a physician and patient and is explicitly sexual or may be reasonably interpreted as sexual, even if initiated by the patient. So-called “romantic” behavior between a physician and a patient is never appropriate, regardless of the appearance of consent on the part of the patient. Such behavior would at least constitute grooming, depending on the nature of the behavior, if not actual sexual misconduct, and should be labeled as such.
If there is an active doctor-patient relationship, patient consent will not be a “get out of jail free card.” There are some relationships, that when terminated, with sufficient time having lapsed, will not violate a professional boundary. There are others that may never be sanitized by terminating the relationship and waiting, for example, one between a psychiatrist and patient over years.
What if the Board gets involved? What if the Board concludes you “did the deed?” These are the range of potential remedies.
- Supervision of the physician in the workplace by a supervisory physician
- Requirement that practice monitors are always in attendance and sign the medical record attesting to their attendance during examination or other patient interactions as appropriate.
- Periodic on-site review by board investigator or physician health program staff if indicated.
- Practice limitations as may be recommended by evaluator(s) and/or the state physicians health program.
- Regular interviews with the board and/or state physician health program as required to assess status of probation.
- Regular reports from a qualified and approved licensed practitioner, approved in advance by the board, conducting any recommended counseling or treatment.
- Completion of a program in maintaining appropriate professional boundaries, which shall be approved in advance of registration by the board.
- The state medical board should have the authority to impose terms or limitations, including suspension, on the physician’s license prior to the completion of the investigation.
- License revocation.
So, the penalties can be severe.
Education and training about professional boundaries in general and physician sexual misconduct in particular should be provided during medical school and residency, as well as throughout practice as part of a physician’s efforts to remain current in their knowledge of professional expectations.
For practicing physicians, because of lack of education or awareness, physicians may encounter situations in which they have unknowingly violated the medical practice act through boundary transgressions and violations. A reduction in the frequency of physician sexual misconduct may be achieved through education of physicians and the health care team. Engagement in accredited continuing medical education that addresses professionalism, appropriate and acceptable behavior, and methods for reporting sexual misconduct should be encouraged among physician licensees and other members of the healthcare team.
The more doctors are aware of the changing landscape, the better they’ll be equipped to prevent or mitigate against allegations of boundary violations. Charges of boundary violations are made against both men and women, straight or gay. They’re not always made by patients. They may be made by staff or colleagues.
The world has changed. Mores from last century are different.
I’m not counseling “No hugging.” I am saying it should be a conscious decision, with awareness of potential consequences if the context or intent is misperceived.
One article from 2012 put it succinctly:
Some practitioners also feel it is permissible to hug patients at times, though, depending on the characteristics of the patient, this can be very dangerous. Context is clearly important in determining to what extent a hug may be thought of in this way. Hugging can cause serious confusion in the professional relationship, be interpreted or experienced in a romantic way by the patient, and can lead to greater intimacy. An important adage to remember is that when it comes to boundaries, “perception is everything.” The misinterpretation of a therapeutic hug as romantic may be impossible to defend.
What do you think?
Yep. It’s all about context. Sometimes a patient wants to hug me. I don’t just stand there like a cigar store Indian. I hug them back.
If someone is hurting, I generally put a hand on or arm around a shoulder. If they pull away, that’s a message (but I don’t recall that ever happening). If they lean against me, I don’t push them away. That’s also a message.
I’ve had several patients ask “can we be friends when I get well?” Sure. And I’ve become friends with physicians who have taken care of me or my family. Tho, admittedly, there’s no real or perceived “power difference” in that case. These relationships have typically proven to be permanent ones.
I think it also depends upon the patient and the context of the visit. I would definitely never make a first move to hug a very young female patient or child of a patient. In my practice, I routinely operated young children. I was always very friendly to them, but would never hug any of them, and always had proctors in the room. Since I had to inject local anesthesia to a number of these young patients, the parents were not always comfortable with that procedure. I had a wide range of ages among my practice. When I first started out, I expected mostly elderly patients, which is typical of DPM practices. While the majority were older, because I practiced in a mixed community, I did see more young people than I initially expected.
I think you should avoid hugging if you can, without giving an impression you are cold or indifferent.
One of my childhood friends brought his elderly grandmother to see a local DPM, many years ago. She was unable to get into the office. This extremely caring doctor actually carried the elderly woman into his office, physically, and returned her to the car. This brought my friend to tears of gratitude. His name was Matthew Borovoy, DPM.
Michael M. Rosenblatt, DPM
The first time I was kissed by a patient, occurred in a labor and delivery suite, where the OB/GYN did not want anesthesia in the room after the epidural was placed.
So aside from peeking in the patient and looking at the monitor periodically, I stayed out of the room.
However, about 30 years ago, when I was in practice, I put in an epidural for a lady in labor, (she was related to someone who worked in the hospital). She beckoned me into the room. I tiptoed a foot or two in. She waved me over to her. I took a few more steps in. She waved me over again. Then when I was standing next to the bedside, she suddenly reached up, pulled me down to her and planted a kiss on my cheek. This was for relieving her labor pain with the labor epidural. I was surprised for sure. I did not expect this. Clearly this was also patient initiated.
As a general rule, I tried to keep my distance from patients because of the issues raised in this article. I became aware of these issues when I went into practice. I had not considered them before that. But even after retirement, I remain very cautious. In a non medical context with people that I know in a few groups, I will occasionally be grabbed by a female for a hug. (They all know I am married, and this is in a business context and a business environment with lots of people around). I still want to recoil from these hugs, because of all of the warnings not to hug when I was in practice.
It is clear that some of us grew up in households and environments where it was routine to hug. But many people did not.
So, I repressed whatever cultural norms that I had before practice, since it was clear that this area was fraught with potential legal danger.
I still will not initiate a hug even though I am long retired from medical practice.
I think it is just safer this way. If we were not in such a litigious society it might be different.
Clearly there are also religious boundaries for some people as well. A former VP would not be alone in a room with another female, for ostensibly religious reasons, but I strongly suspect it was to protect his reputation as a politician.
Also in terms of physical touch, I became extremely leery about patting anyone on a shoulder, arm, etc. because their boundaries were such that they might recoil. I just had to train myself not to touch anyone, other than my direct family members.
Such is life in today’s litigious society.
I’m a hugger, and always will be, but always with my assistant present. When we operate on a teen, they become like one of our kids for a year.
Medical Justice got me promptly out of a pickle after a kiss on the top of the scalp of a college student who was happy with our services and going back to school. The next day, the patient’s mother called my office and expressed to me that the Peck on her daughter‘s head was inappropriate and setting a bad example for her college aged daughter. I was so angry, I am grateful that I had the fortitude to hang up on the mother and seek advice. Would anyone ever want to go to the Board about a subject like this? Inappropriate kissing of a teen. Yikes. Always have a chaperone. People are friggin nuts out there. Merry Christmas!
I do hug patients. Most are female, some are male, all ages, generally patient initiated. But… I have a very small dental practice, and the majority of the patients I hug have been with me for 10-30 years. They are like family. As for wee little ones, I hug them, too, in front of the parent in the room, and generally because going to the dentist is rather traumatic and I’d prefer they didn’t remember all of the trauma. It does help that I am a petite Mom who doesn’t initiate things.