| Defined as whenever a physician disregards the professional limits that exist as a part of their relationship with patients and/or other members of the healthcare team, boundary violations may include (but are not limited to) disregarding physical, sexual, emotional, social, spiritual, cultural and financial limits that exist between physicians and the above groups.
Policies for dealing with physician boundary violations should be aimed at prevention and early intervention. These policies should also be similar for all members of healthcare teams. However, the College of Physicians and Surgeons of Alberta, hereafter referred to as the College, recognizes that differences do exist for physicians due to a potential power differential in the healthcare system and due to the fact that most physicians are not employees of the health authorities and thus disciplinary mechanisms may vary from those related to employees.
In situations where the physician involved in a boundary violation is considered an employee or under contract with the health authority. The college recommends the mechanisms to deal with such individuals. These include, but are not limited to: - clear policies on inappropriate workplace behavior,
- educational programs to inform all healthcare members of workplace expectations,
- proper methods to report boundary violations which are made available to all members of the healthcare team,
- a system to attempt to deal with the boundary violation,
- clear communication with the college for resources and managing such behaviors; and
- a readiness to terminate contracts and employment if the boundary violation does not cease or is deemed severe enough to result in immediate termination of the physicians involvement with the health region.
The College has previously recognized that boundary violations are on a continuum, which should not be artificially stratified by severity. Thus, it maintains full discretion over what constitutes a boundary violation and what the appropriate penalty will be in each case. When inappropriate boundary violations occur, the perpetrator involved should be held accountable and measures taken to prevent recurrence. Once becoming aware of a boundary violation the College must then decide what information needs to be gathered, what assurances are needed to determine fitness to practice and the monitoring required. With respect to sexual boundary violations, the College deems these interactions to always be unacceptable, regardless of consent. All sexual boundary violations regardless of how they come to the attention of the College will be investigated. 1. Identification of physicians demonstrating a boundary violation: - self report
- report by a colleague
- report by a treating healthcare professional
- identification through a complaint process
2. Information gathering in situations of an alleged boundary violation. Regardless of the way in which a physician is identified, the process to determine their fitness to practice will be similar and include the following: - Reports of individuals affected by the boundary violation.
- Reports from colleagues of work performance.
- Report from health authorities involved in the situation and past physician performance evaluations.
- Additional investigations or requirements.
If there is a serious concern about a physician’s fitness to practice, they can be asked to voluntarily withdraw from practice until all information is gathered or they could be suspended until fitness to practice was determined. This is a serious matter but patient safety must come first and the College will need to ensure that there is not a risk to patients. In both cases, the physician will be reminded to seek legal advice to ensure a fair process. 3. Additional information may include the following: - Cognitive assessment and neuropsychological testing to determine ability to practice.
- Physical assessment tailored to the specific problem: i.e.: orthopedic surgeon, neurologist, sleep disorder specialist, internists.
- Psychiatric assessment.
Multidisciplinary assessment for complex cases or when there is a direct patient concern involved. Physicians must agree to allow the College access to medical records which confirm their fitness to practice. 4. Potential outcomes: - Unfit to practice with no chance of recovery.
- Unfit to practice at the time of assessment but improvements likely.
- Fit to practice with practice limitations or restrictions.
- Fit to practice with no restrictions.
5. Monitoring: Boundary violations can impair the ability to practice, but in many cases physicians can be rehabilitated. Ongoing monitoring is required to ensure compliance to recommendations of treating experts, to reassess for fitness to practice and to ensure compliance with any practice restrictions or limitations. This can include the following: - Reports from treating physicians.
- Reports from colleagues or designated practice monitor.
- Reassessment by a third party.
- Practice visits or audits to review their practice.
- Competency assessment.
- Monitoring of billing or medical records to determine compliance to practice restrictions.
6. Continuing Care Contracts: These contracts are entered into to ensure compliance to the requirements as a condition of continued practice as outlined as a result of resolution of a disciplinary matter or as agreed to by the physician. References Appropriate boundaries in pediatrician-family patient relationship. Committee on Bioethics. August 1999. Pediatrics 104(2):334-336. Gabbard G. Patient-therapist boundary issues. Psychiatric Times. October 2005. Vol XXII(12). Website: www.psychiatrictimes.com Microys G, Prather V, Jones B, Robertson R. Physicians and family support program perspectives: boundaries: invisible but critical and worth thinking about. Website: www.albertadoctors.org Roback H, Strassberg D, Iannelli R, Finlayson AJ R, Blanco M, Neufeld R. Canadian Journal of Psychiatry. May 2007. 52(5):315-322. Sexual misconduct statement and policy. Policy statement of Tennessee State Board of Medical Examiners. Sept 1993. Texas Medical Association, Boundary violations. Website: www.texmed.org. |